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Digitized  by  tine  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/essentialsofpriOOhart 


ESSENTIALS  Z^^^^^^,^ 

OF  THE  „.__^ 

PRINCIPLES  AND  PRACTICE 

OP 

MEDICIITE. 

A  HANDBOOK 

FOR  STUDENTS  AND  PRACTITIONERS. 

BY 

HENRY  HARTSHORNE,  A.M.,  M.D., 

LATELY  PROFESSOR  OF  HYGIENE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA,  AND 

PROFESSOR  OF  HYGIENE  AND  DISEASES  OF  CHILDREN   IN  THE  WOMAN'S 

MEDICAL  COLLEGE  OF  PENNSYLVANIA;   EDITOR  OF  AMERICAN 

EDITION  OF   "  REYNOLDS'   SYSTEM  OF  MEDICINE,"  ETC. 

FIPTH  EDITION,  THOROUGHLY  REVISED  AND  IMPROVED. 


^rt^  |{tt«W  mi  %m\i-^tm  )fk%M\n%. 


PHILADELPHIA: 

HEiTRY  C.  LEA'S  SOl^r  &  CO, 
1881. 


c^. 


Entered,  according  to  the  Act  of  Congress,  in  the  year  1881,  by 

HENRY  C.  LEA'S  SON  &  CO., 
In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


^ 


J.   FAOAN   t   BON, 
ELECTROTTPERS,    PHILAD'A. 

Xr^ a* 


TO  THE 

FIFTH  EDITION 


QINCB  the  publication  of  the  last  edition  of  this  work,  in 
1874,  medical  knowledge  and  thought  have  received  addi- 
tions such  as,  fully  set  forth,  might  occupy  several  volumes. 
If  it  should  seem  a  hopeless  task  to  present  a  summary  of  the 
most  important  of  these  within  the  compass  of  a  few  score  of 
pages,  such  an  endeavor  appears,  nevertheless,  to  be  called  for 
by  the  purpose  and  antecedents  of  this  volume  of  "  Essen- 
tials." It  has  therefore  been  undertaken  ;  with  what  approx- 
imation to  success,  my  readers  must  judge.  Several  liundred 
brief  additions  have  been  made  throughout  the  work ;  a  num= 
ber  of  new  subjects  have  been  written  upon,  especially  in  con- 
nection with  the  pathology  of  the  Nervous  System ;  the  illus- 
trations have  been  considerably  added  to,  and  a  large  number 
of  new  and  carefully  selected  formulae  for  the  administration 
of  medicines  have  been  introduced.  An  account  is  given,  also, 
for  the  first  time,  of  the  method  of  prescribing  according  to 
the  Metrical  system ;  and  a  section  is  added  upon  Eyesight, 
its  Examination  and  Correction. 

While  thus  endeavoring  to  do  justice  to  all  real  medical 
improvement  and  progress,  it  appears  necessary  for  me  still 
to  remain  in  the  minority  upon  a  few  subjects  of  current 
opinion.  Especially,  it  does  not  seem  to  me  that  the  time  has 
arrived  for  Clinical  Medicine  to  surrender  at  discretion  to 
Physiological  Therapeutics.    Whatever  of  valuable  suggestion 


IV  PEEFACE. 

or  explanation  may  rightly  proceed  from  the  physiological  or 
toxicological  laboratory,  the  true  field  of  decision  in  Experi- 
mental Medicine  must,  according  to  my  belief,  always  lie  in 
clinical  observation  and  experience.  Some  farther  remarks 
upon  this  topic,  which  has  latterly  become  one  of  prominent 
importance,  are  ventured  upon  near  the  close  of  the  Introduc- 
tion. 

The  besetting  medical  error  of  almost  all  periods,  the  nimia 
diligentia,  doing  overmuch,  was,  about  the  middle  of  this  cen- 
tury, put  aside  for  a  time,  by  an  era  of  scepticism  in  therapeu- 
tics, logically  followed  by  inert  expectancy  Now  we  have, 
under  new  theories,  a  revival  of  heroic  medication ;  with  the 
use  of  drugs,  especially  narcotics  and  stimulants,  capable  of 
great  usefulness,  but  also  of  misuse,  as  serious  as  ever  befell 
the  lancet,  calomel,  or  antimony  in  former  times.  Through  all, 
however,  true  science  must  in  the  end  prevail. 

References  to  authors  cited  in  this  book  have,  through  accu- 
mulation, become  somewhat  cumbrous.  I  have,  nevertheless, 
concluded  to  retain  most  of  them ;  believing  that  instruction 
may  be  derived  from  even  so  partial  a  record  of  the  recent 
history  of  medical  observation  and  opinion. 

Although  still  having  to  regret  many  imperfections,  I  trust 
that  my  readers,  to  some  of  whom  I  send  greeting  as  far  off 
as  Japan,  may  find  the  work,  thus  revised,  more  serviceable 
than  hitherto,  in  facilitating  their  acquaintance  with  the  most 
important  facts  and  principles  of  Practical  Medicine. 

H.  H. 
Geemantown,  Philadelphia, 
August,  1881. 


CONTENTS. 


INTRODUCTION:  Systems  of  Medicine 


PAGE 

.     13 


PART  I. 

PRINCIPLES  OF  MEDICINE. 


SECTION  I. 


GENERAL  PATHOLOGY. 


MoEBiD  States  of  the  System  2  6 

Fever 26 

Toxaemia 2Y 

Anasmia 31 

Plethora 32 

Oacliexia 32 

MoEBiD  States  of  Oegans     .  44 

Hypertrophy     ....  44 


Atrophy 

FARE 

.    45 

Irritation 

.    46 

Inflammation    .     .    . 

.     47 

Chronic  Inflammation 

54 

Degeneration     .     .     . 

65 

Morbid  Growths    .     . 

56 

Neuropathology     .     . 

60 

Modes  of  Death      .     .     . 

66 

SECTION  II. 


SEMEIOLOGY. 


1.  Symptomatology. 
Digestive  System 
Circulation    .     . 
Respiration  .     . 
Skin     .... 
Secretions     .     . 
Motor  Apparatas 
Sensory  Apparatus 
Psychical  Functions 
General  Vital  Condition 
1* 


67 
67 
69 
73 
74 
75 
93 
94 
97 
98 


2.  Physical  Diagnosis     .     .     98 

Inspection 98 

Mensuration  and  Palpa- 
tion   99 

Spirometry  .     .     .     .     .  100 

Percussion 101 

Auscultation     .     .     .     .103 
Exploration  of  the  Heart  110 
Exploration  of  the  Abdo- 
men  115 

V 


VI 


CONTENTS, 


Diagnosis  of  Diseases  of 

"Women 116 

Laryngoscopy  .  .  .  .119 
The  Ophthalmoscope .  .  121 
The  Sphygmograph    .     .124 


Temperature  in  Disease  .  128 
Pneumatic  Aspiration     .  133 

Inspection  OF  THE  Dead  Body  134 

Medioo-Legal  Examina- 
tions   137 


SECTION  III. 
GENEEAIy    THERAPEUTICS. 


Classification  of  Kemedies  138 
Balancive  Measures  .  .  139 
Antiphlogistic  Treatment  141 
Febrifuge  Treatment .  .151 
Supporting  Treatment  .  154 
Calmative  Treatment  .  163 
Antidotal  Treatment .  .  164 
Alterative  Treatment  .  169 
Medioal  Electricity  .  .171 
Hydropathy 175 


Hot- Air  Baths  . 
Movement-cure. 


.     .  175 
.    .  177 
.    .  177 
Inhalation  and  Atomiza- 

tion 179 

Hypodermic  Medication .  183 
Transfusion  of  Blood  .     ..  187 
General    Conclusions    and 
Maxims 191 


SECTION  IT 

NOSOLOGY. 


Classification  of  Diseases  192 

Phlegmasia 192 

Zymoses 192 


Cachexise 193 

Neuroses .193 

Ataxias 193 


PART  II. 

SPECIAL  PATHOLOGY  AND  PRACTICE. 


Affections  of  the  Eespiea- 

TOET  System 194 

Pneumonia 194 

Cirrhosis  of  the  Lung      ,  200 

Pleurisy 201 

Abscess  of  the  Lung  .  .  206 
Gangrene  of  the  Lung  .  206 
Emphysema  of  the  Lung  207 
CoUapse  of  the  Lung .     .  207 

Bronchitis 208 

Asthma 210 


Bronchial  Dilatation  . 
Chronic  Nasal  Catarrh 
Laryngitis     .... 

Aphonia 

Laryngismus  Stridulus 

Croup  

Pleurodynia  .... 
Intercostal  Neuralgia 
Thoracic  Myalgia  .  . 
Phthisis  Pulmonalis   . 


.  214 

.  215 
.  217 
.  218 
.  219 

.  220 
.  226 

.  227 
.  227 
.  227 


CONTENTS. 


VU 


PAGE 

Affections   of    the   Heart 

AND  Acuta 239 

Pericarditis 239 

Endocarditis  ....  242 
Valvular  Disease  .  .  .  244 
Dilatation  of  the  Heart ..  24G 
Hypertrophy      of      the 

Heart 247 

Fatty    Degeneration     of 

the  Heart 248 

Sudden  Death   in  Heart 

Disease 249 

Angina  Pectoris  .  .  .  250 
Exophthalmic  Goitre ,     .  250 

Palpitation 252 

Cardiac  Exhaustion  .  .  253 
Aneurism     of    Thoracic 

Aorta 253 

Aneurism  of  Abdominal 

Aorta 255 

Affections  of  the  Alimen- 
tary System 257 

Stomatitis 257 

Tonsilhtis 260 

Pharyngitis 261 

Retropharyngeal  Abscess  262 
Stricture  of  (Esophagus  .  262 

Gastritis 263 

Chronic  Gastritis  .  .  .  264 
Anti-emetic  Remedies  .  265 
Ulcer  of  the  Stomach ,  .266 
Cancer  of  the  Stomach  .  267 

Dyspepsia 268 

Constipation      ....  272 

Enteritis 273 

Peritonitis 275 

CoHc 277 

Common     Remedies    in 

Colic 288 

Obstruction  of  the  Bow- 
els     284 

Cholera  Morbus     .     .     .  287 

Diarrhoea 289 

Cholera  Infantum .  .  .  291 
Dysentery 294 


PAGE 

Hemorrhoids  ....  297 
Fissure  of  the  Anus  .  .  300 
Prola])sus  Ani  ....  301 

Affections  of  the  Liver  .  301 
Acute  Congestion .  .  .  301 
Chronic  Congestion   .     .  302 

Hepatitis 303 

Abscess  of  the  Liver  .     .  303 

Jaundice 305 

Acute  Yellow  Atrophy  .  307 
Pigment  Liver  .     .     .     .308 

Cirrhosis 309 

Fatty  Liver 310 

Waxy  Liver 311 

Syphilitic  Liver  .  .  .312 
Cancer  of  the  Liver  .  .  312 
Hydatids  of  the  Liver  .  313 
Tubercle  of  the  Liver  .  313 
DUatation  of  the  Gall- 
bladder       314 

Affections  of  the  Spleen   .  314 

Affections  of  the  Kidneys 

AND  Bladder 315 

Renal  Congestion  .     .     .315 

TJrfBmia 315 

Nephritis 316 

Bright's  Disease     .     .     .  317 

Lithiasis 323 

Diabetes  Insipidus  .  .  325 
Diabetes  Mellitus  .  .  .326 
Hydronephrosis  .  .  ,  329 
Pyonephrosis  ....  330 
Cancer  of  the  Kidney  .  330 
Tubercle  of  the  Kidney  ,  331 
Amyloid  Kidney  .  .  .  331 
Hydatids  of  the  Kidney  .  332 

Cystitis 333 

Retention  of  the  Urine  .  334 
Enuresis 335 

Affections    of    the    Brain 
AND  jSTertous  System    .     .  335 
Inflammation      of     the 

Brain 335 

Hydrocephalus  ....  340 
Brain  Exhaustion  .     .     .  340 


vm 


CONTENTS. 


PAGE 

Ramollissement     .     .     .  342 

Ophthalmia 343 

Otitis  .......  346 

Apoplexy 348 

Spinal  Meningitis  .  .  .  353 
Softening  of  the  Cord  .  353 
Spinal  Irritation  .  ,  .354 
Cerebral      and      Spinal 

Sclerosis 355 

Paralysis 360 

Locomotor  Ataxy  .     .     .  368 

Athetosis 370 

Infantile  Paralysis      .     .  371 

Epilepsy 372 

Catalepsy 375 

Heatstroke 376 

Insomnia 377 

Night-terrors    ....  378 

Convulsions 379 

Chorea 382 

Aphasia 384 

Tetanus 384 

Hydrophobia     ....  387 

Hysteria 390 

Hystero-Epilepsy  .     .     .  391 

Neuralgia 392 

Delirium  Tremens .     .     .  395 

Methomania 397 

Insanity 398 

Hemoeehages 400 

Epistaxis 401 

Hemorrhage    from    the 

Mouth 402 

Hemoptysis 402 

Pulmonary  Apoplexy  .  408 
Hgematemesis    ....  403 

Hsematuria 404 

Hemorrhage    from    the 

Bowels 404 

Vicarious  Hemorrhage   .  404 

Uterine  Hemorrhage  .     .  405 

Deopsioal  Affections  .     .     .  405 

Acute  General  Dropsy    .  406 

Ascites 406 

Ovarian  Dropsy     .     .     .  406 


PAGE 

Zymotic  Diseases    ....  409 

Variola 409 

Varioloid 411 

Vaccination 411 

Varicella 414 

Scarlatina 415 

Measles 419 

Rotheln 420 

Mumps 422 

Hooping-Oough      .     .     .  422 

Diphtheria 424 

Glanders ».  431 

Influenza 432 

Dengue 432 

Malarial  Fever  ....  433 

Intermittent   .     .     .  438 

Eemittent  .     .     .     .439 

Pernicious.     ,     .     .  445 

Prophylaxis   of  Malarial 

Fever 447 

Typho-Malarial  Fever  .  448 
Yellow  Fever  ....  449 
Eelapsing  Fever  .  .  .  455 
Oerebro-Spinal  Fever  .  457 
Typhus  Fever  .  .  .  .461 
Typhoid  Fever  ....  464 

Plague 473 

Erysipelas 474 

Flood  Fever  of  Japan  .  475 
Puerperal  Fever    .     .     .  476 

Cholera 478 

Diatheses 497 

Rheumatism      ....  497 

Gout 502 

Scurvy 505 

Scorbutic  Dysentery  .     .  506 

Syphilis 507 

Constitutional  Syphilis  .  609 
Syphilizatiou     .     .     .     .511 

Gonorrhoea 512 

Scrofula 513 

Rickets     .     .     .     ...     .  515 

Spinal  Caries     ....  516 

Coxalgia 517 

An£emia 518 


CONTENTS. 


IX 


Pernicious  AnaBmia    .     .519 

Chlorosis 521 

Beriberi 522 

Mjxcedema 523 

Leucocythfemia  .  .  .  524 
Hodgkin's  Disease .  .  .  525 
Pya3rnia;  Septicfemia.  ,  526 
Thrombosis ;  Embolism  .  528 
Mucous  Disease  .  .  .  530 
Angeioleucitis   .     .     .     .530 

Whitlow 531 

Onychia;  Onyxis  .     .     .  631 

Carbuncle 532 

Addison's  Disease .     .     .  533 

Goitre 534 

Diseases  of  the  Skin  .     .     .  536 
Exanthemata    ....  536 

Papulfe 537 

Vesicul89 538 

Bulte 541 

Pustulaa 542 

Squamae 543 

Maculae 547 

Hypertrophiaa   ....  547 

Tubercula 549 

Haemorrhagiae  ....  554 

Neuroses 555 

Parasiticae 556 

Syphilida 560 

Poison -Vine  Eruption    .  561 


PACE 

Chilblains 561 

Burns  and  Scalds  .     .     .  562 

Unclassified  Affections  .  562 
Amenorrhcea  ....  562 
Dysmenorrhoea.  .  .  .  564 
Menorrhagia      ....  565 

Leucorrhcea 566 

Irritable  Uterus  .  .  .  566 
Ulcers  of  the  Uterus  .  .  568 
Uterine  Tumors  .  .  .569 
Prolapse  of  Ovaries  .  .  578 
Spermatorrhoea      .     .     .  574 

Entozoa 576 

Cestoid  Worms ....  577 
Trematode  Worms  .  .  579 
Neraatoid      or      Round 

Worms 580 

Epizoa 585 

Poisons 585 

Bites  of  Serpents  .     .     .  589 

Asphyxia 590 

Eyesight,  its  correction  ,  592 

Formula 601 

Medicines  referred  to .  .  601 
Miscellaneous  ....  624 
Explosive      Pharmacal 

Compounds  ....  643 
Metrical  Prescriptions  ,  644 
Aliments 648 

Disinfectants 653 


Index  of  Diseases  and  Formula 655 

General  Index 657 


ILLUSTRATIONS. 


FIG.  PAGE 

1.  Yellow  Tubercle    ...  36 

2.  Gray  Tubercle  ....  36 

3.  Tul)erc]e  Corpuscles  .     .  36 

4.  Multinucleated  Cell     .     .  37 

5.  Miliary  Tubercles  ...  38 

6.  Apex  of  Tuberculous  Lung  39 

7.  Cicatrix  of  Lung    ...  40 

8.  Giant  Cells 43 

9.  Hypertrophy  of  Heart     ,  45 

10.  Pus  Corpuscles       ...  52 

11.  Bands  of  Lymph    ...  53 

12.  Fatty  Infiltration   ...  56 

13.  Cancer  Cells      ....  57 

14.  Colloid  Cancer  ....  58 

15.  Colloid  Cancer  ....  58 

16.  Myeloid  Sarcoma  ...  58 

17.  Colloid  Cancer ....  59 

18.  Lateral  View  of  Brain     .  64 

19.  Inner   Sui'face  of   Hemi- 

sphere of  Brain      .     .  64 

20.  Psycho-motor  Centres     .  65 

21.  Foreign  Bodies  in  Urine  77 

22.  Urea 80 

23.  Uric  Acid 80 

24.  Carbonate    of     Calcium, 

and  Hippuric  Acid      .  81 

25.  Oxalate  of  Calcium     .     .  81 

26.  Oxalate  of  Calcium     .     .  81 

27.  Crystals  of  Tyrosin     .     .  82 

28.  Crystals  of  Leucin      .     .  82 

29.  Nitrate  of  Urea    ...  84 

30.  Urates 85 

31.  Urate  of  Sodium    ...  85 

32.  Urate  of  Sodium    ...  86 

33.  Urate  of  Ammonium      .  86 

34.  Triple  Phosphate  ...  87 

35.  Cystine 87 


FIG.  PAGB 

36.  Vaginal  Epithelium     .     .     88 

37.  Epithelial  Cells      ...     90 

38.  Uric  Acid  Calculus     .     .     92 

39.  Mulberry  Calculus       .     .     92 

40.  Area  of  Hepatic  Dulness     101 

41.  Anterior    Thoracic     Re- 

gions    ......  104 

42.  Posterior    Thoracic   Re- 

gions          105 

43.  Pneumothorax       .     .     .  106 

44.  Normal  Position  of  Heart  110 

45.  Distended  Pericardium    .  112 

46.  Diagram  of  Heart's  Ac- 

tion     113 

47.  Auricular- Systolic    Mur- 

mur      114 

48.  Ventricular-Systolic  Mur- 

mur   114 

49.  Ventricular-Diastolic 

Murmur   .....  114 

50.  Sims'  Speculum      .     .     .117 

51.  Sims'  Depressor     .     .     .  118 

52.  Fergusson's  Speculum      .  118 

53.  Sims'  Copper  Sound  .     .118 

54.  Emmet's  Silver  Probe      .  118 

55.  Sponge  Tent      .     .     .     .119 

56.  Laryngoscope    ....  120 

57.  Laryngoscopic  Drawing     120 

58.  Laryngoscopic  Drawing     120 

59.  Ophthalmoscope    .     .     .  122 

60.  Tubercle  of  Choroid   .     .  122 

61.  Choked  Disk     ....  123 

62.  Marev's  Sphygmograph     124 

63.  PnW  Tracing   .     .     .     .125 

64.  Radial  Pulse  Tracing       .  126 

65.  Tracing  of  Healthy  Pulse  126 

66.  Radial  Pulse  Tracing      .  126 


xu 


ILLUSTRATIONS. 


FIG-  PAGE 

67.  Pulse  of  Aortic  Eegurgi- 

tation 126 

68.  Pond's  Sphygmograph  .  127 

69.  Pulse  in   Thoracic  An- 

eurism     128 

70.  Pulse    in   Thoracic  An- 

eurism     128 

71.  Pulse  in  Bright's  Disease  128 

72.  Typical  Ranges  of  Tem- 

perature     .     .     .     .130 

73.  Temperature  in  Hectic 

Fever 132 

74.  Pneumatic  Aspirator     .  133 

75.  Apparatus    for     Trans- 

fusion      188 

76.  Red  Hepatization      .     .195 

77.  Red  Hepatization     ,     .198 

78.  Gray  Hepatization     .     .  196 

79.  Pleuritic  Effusion      .     .  202 

80.  Vesicular  Emphysema  .  207 

81.  Dilated  Bronchi   .     .     .214 

82.  (Edema  of  Glottis     .     .  217 

83.  Trachial     False    Mem- 

brane       221 

84.  Bronchial   False    Mem- 

brane       222 

85.  Durham's  Canula      .     ,  224 

86.  Bryant's  Oanula  .     .     .225 

87.  Pericarditis, with  Lymph  240 

88.  Thickening     of     Mitral 

Valve 244 

89.  Atheroma     of     Aortic 

Valve 245 

90.  Diagram      of      Cardiac 

Murmurs     ....  246 

91.  Fatty  Degeneration  .     .  248 

92.  Rupture  of  Heart      .     .  249 

93.  Exophthalmic  Goitre     .  251 

94.  Aneurism  of  Aorta  .     .  254 

95.  Aneurism  of  Aorta   .     .  255 

96.  Ulcer  of  Stomach      ,     .  266 

97.  Perforating     Ulcer     of 

Stomach 267 

98.  Sarcinse 270 

99.  Gall-stones      ....  280 

100.  Calculi  in  Gall-bladder  .  281 

101.  Cholesterin  Tablets  .     .  281 

102.  Intussusception    .     .     .  284 

103.  Fatty  Liver     .     ...  310 


PIG.  PAGE 

104.  Renal  Hyperaemia     .     .  316 

105.  Renal  Cysts     ....  317 

106.  Casts  in  Bright's  Disease  318 

107.  Granular  Kidney .     .     .  319 

108.  Renal  Epithelium     .     .  320 

109.  Waxy  Casts     .     .     .     ,321 

110.  Sugar  Fungus.     .     .     .328 

111.  Miliary  Aneurisms    .     .  349 

112.  Cerebral  Hemorrhage   .  350 

113.  Spinal  Sclerosis    .     .     .  355 

114.  Lumbar  Sclerosis      .     .  356 

115.  Sclerosed  Patch  .     .     .357 

116.  Advanced  "Wasting  Palsy  366 

117.  Pseudo   -   hypertrophic 

Paralysis     ....  367 

118.  Hystero-epilepsy .     .     .  392 

119.  Vaccination  Scratches  .  413 

120.  Temperature  in  Yellow- 

Fever      451 

121.  Cerebro-spinal  Fever     .  458 

122.  Ulceration     of    Peyer's 

Glands 467 

123.  Syphilitic  Teeth   .     .     .510 

124.  Blood  in  Leucocythsemia  525 

125.  Thrombosis  in  Saphena 

Vein 528 

126.  Embolus  of  Pulmonary 

Artery 529 

127.  Bronchocele    ....  .534 

128.  Elephantiasis  Arabum  .  548 

129.  Acarus  Folliculorum      .  550 

130.  Acarus  Folliculorum      .  550 

131.  Group  of  Acari  Follicu- 

lorum     .     .         .     .  551 

132.  Acarus  Scabiei — Male   .  557 

133.  Microsporon  Furfur  .     .  558 

134.  Hairs  from  Tinea  Ton- 

surans     560 

135.  Hodge's  Pessary  .     .     .568 

136.  A.  H.  Smith's  Pessary  .  568 

137.  Echinococcus  Hominis  .  577 

138.  Taenia  Solium  .     .     .     .578 

139.  Trichocephalus  Dispar  .  581 

140.  Trichina  in  Muscle    .     .  582 

141.  Encysted  Trichina    .     .  583 

142.  Trichina,  Magnified  .     .  583 

143.  Orthoscopic  Glasses,     ,  598 

144.  Diagram  to  show  Astig- 

matism   600 


THE 


PRINCIPLES  AND  PRACTICE 


OF 


MEDICINE. 


INTRODUCTION. 

SYSTEMS  OF  MEDICINE. 

BEFOEE  Lord  Bacon,  and  before,  in  fact,  all  others  whose 
writings  have  come  down  to  us,  Da  Vinci,  the  architect, 
painter,  and  engineer,  proclaimed,  in  the  first  half  of  the  six- 
teenth century,  that  in  the  study  of  natural  truth  we  must  con- 
sult experience.,  experience  rather  than  reason.  "  Those,"  said  he, 
"who  in  the  study  of  the  sciences  do  not  consult  nature,  but 
authors,  are  not  the  children  of  nature  ;  they  are  only  her  grand- 
children." "Nature  begins  from  the  reason  and  ends  in  expe- 
rience, but  we  must  take  the  reverse  course, — begin  from  the 
experiment  and  try  to  discover  the  reason."  "Theory  is  the 
general,  but  experiments  are  the  soldiers.'''' 

Not  that  these  were  the  first  utterances  in  all  time  in  favor  of 
the  value  of  observation  and  experiment  in  acquiring  a  knowl- 
edge of  nature  ;  but  only  that  now,  for  the  first  time,  these  began 
to  be  the  governing  ideas  of  science  and  philosophy.  Aristotle 
was  a  naturalist,  although  still  more  emphatically  a  dialectician  ; 
Leucippus  and  Democritus  founded  a  school  whose  dependence 
was  almost  exclusively  on  the  evidence  of  the  senses ;  and  even 
Cicero,  who  paid  little  attention  to  natural  science,  wrote  this 
wise  sentence  :  ''Praistat  naturae  voce  doceri,  quam  ingenio  suo 
sapere."  But  it  is  especially  interesting  to  us  to  recall  the  fact 
that  most  clearly,  perhaps,  of  all  the  ancients,  was  this  reliance 
upon  nature  enunciated,  and  most  practically  was  it  exemplified, 
by  Hippocrates  of  Cos.  He  asserted  again  and  again  in  his 
works  that  "  nothing  should  be  affirmed  concerning  the  nature 
of  man  until  after  having  acquired  a  certainty  of  it  by  the  aid 
of  the  senses."  And,  although  this  may  seem  very  obvious 
indeed  to  us,  yet  it  is  a  familiar  fact  that  the  great  intellects  of 
2  13 


14  INTRODUCTION. 

antiquity,  from  the  sages  of  the  Vedas  and  from  Pythagoras  and 
Plato  downward,  had  more  confidence  in  the  tnath-compelling 
powers  of  their  own  reason  ;  and  even  Hippocrates  himself  often 
forgot  his  own  maxims,  and  became  dogmatic  beyond  his  knowl- 
edge. 

It  is  not  my  purpose  here  to  go  into  any  historical  discussion 
of  philosophy,  which  would  be  inappropriate  in  this  place.  Nor 
will  I  attempt  to  crowd  into  a  few  pages  the  history  of  medicine 
itself.  But  it  appears  to  me  that  I  cannot  better  occupy  space, 
in  this  introduction,  than  by  endeavoring  to  place  before  the 
mind  of  the  reader  such  a  succinct  view  of  the  most  essential 
phases  and  mutations  of  medical  opinion,  in  times  past  and 
present,  as  will  enable  us  to  apprehend  all  that  bears  upon  the 
aspects  and  prospects  of  the  theory  and  practice  of  Medicine. 

In  the  midst  of  the  multitude  of  authors  who  have  written 
upon  medicine,  in  every  age  which  has  possessed  a  literature, 
the  number  of  cardinal  ideas,  of  distinctive  methods,  opinions, 
or  principles,  has  not  been  great.  Those  who  may  be  considered 
to  have  been  original  thinkers  or  leaders  in  medical  philosophy  • 
have  been  few ;  or,  if  we  cannot  refuse  to  a  larger  number  the 
credit  of  originality,  yet  that  of  actual  novelty  is  not  often  theirs, 
as  they  have  merely  started  anew  an  idea,  a  principle,  a  system, 
or  theory,  which  had  long  ago  its  propounders,  its  advocates, 
and  its  opposers,  although  it  may  have  been  again  forgotten. 

Yet,  few  as  these  essential  ideas  have  been,  it  will  be  impos- 
sible to  do  more  than  mention  them,  as  it  were,  in  catalogue  at 
present. 

A  work,  for  example,  might  be,  and  more  than  once  has  been, 
written  upon  the  doctrines  of  Hippocrates,  and  of  the  writings 
classed  under  his  name  alone.  Suffice  it  for  us  to  recollect  that 
the  leading  idea  of  this  greatest  of  physicians  was  reliance  upon 
and  observation  and  imitation  of  nature.  Yet  he  theorized  upon 
health  and  disease,  upon  the  four  elements  and  the  four  humors, 
and  his  system  has,  therefore,  been  styled  Dogmatic.  To  him, 
also,  is  traced  the  principle  of  medication  by  contraries ;  ra  havria 
Tuv  kvavTLuv  kariv  'irjuara.  The  greatest  value  of  the  Hippocratic 
writings  undoubtedly  consists  in  their  numerous  and  admirable 
descriptions  of  the  symptoms  of  disease,  and  of  the  relations  of 
symptoms  to  prognosis.  The  study  of  hygienic  laws  and  influ- 
ences also  received  from  his  school  much  attention. 

Contrasted  with  the  Hippocratic  reflective  or  dogmatic  method 
of  studying  nature,  was  the  more  detailed  and  less  systematic 
plan  of  the  contemporaneous  Cnidian  school. 

Later,  with  Philinus  and  Serapion  of  Alexandria,  the  distinctly 
Empirical  method  was  promulgated,  in  which  observation,  and 
this  alone,  especially  as  to  the  use  of  remedies,  was  urged.  No 
reasoning  about  why  or  how^  but  only  what^  engaged  the  minds 
of  these  industrious  men ;  whose  materials  thus  accumulated 
only  too  fast  for  their  limited  powers  of  classification.  Their 
most  elegant  writer  was  Aretaeus,  who  is  not  always  credited 
to  them,  but  whose  descriptions  of  disease  have  seldom  been 
equalled,  even  down  to  our  own  day. 

It  is  less  easy  to  characterize,  in  a  few  words,  the  school  curi- 


S  Y  S  T  E  M  S    (>  F     M  E  D  I  C  I  N  E  .  ]  5 

ously  called  Mvtlunlist,  which  orif^inatod  with  the  opinions  of 
Clcoplianlus  of  Alexandria,  and  of  Asclepiades  the  liithynian, 
the  friend  of  Cicero,  and  was  estahlishcd  hy  Themison,  their 
disciple,  at  Rome.  Disniis.sing  the  expectant  study  of  the  course 
of  diseases  inculcated  h}'  Hippocrates,  whicli  they  laughed  at  as 
a  "meditation  upon  death,"  and  denying  his  theory  of  "coctiou" 
and  "crisis,"  tht^y  dogmatized  in  a  diflereut  way  upon  the  changes 
occurring  under  disease  in  the  condition  of  the  solid  structures 
of  the  hody,  and  in  the  movement  of  its  atomic  com])onents. 
Making  hut  two  essentially  different  pathological  states,  the 
"laxum"  and  the  "strictum,"  they  simplified  the  theory  of 
medicine  very  much.  Chielly,  however,  was  Asclepiades  dis- 
tinguished for  the  moderation  of  his  practice  ;  rejecting  complex, 
violent,  and  perturhatory  remedies,  and  aiming,  as  he  said,  to 
cure  "  tuto,  cito,  et  jucunde."  A  somewhat  complicated  course 
of  alterative  treatment  is,  however,  ascrihed  to  his  successors 
by  Crelius  Aurelianus,  under  the  name  of  the  "  metasyncritic 
circle." 

The  most  judicious  as  well  as  one  of  the  most  learned  of  phy- 
sicians was  Aulus  Cornelius  Celsus.  He  selected  from  the  opin- 
ions and  practice  of  his  predecessors  and  contemporaries  those 
of  the  greatest  soundness  ;  so  that,  not  having  propounded  any 
exclusive  dogma,  nor  yet  being  limited  l)y  the  narrow  results  of 
observation  alone,  he  may  be  justly  styled  eclectic;  or,  as  that 
term  has  been  made  odious  of  late  by  the  usurpation  of  a  set  of 
pretenders,  episynthetic,  or  comprehensive^  might  be  a  preferable 
title. 

Galen,  less  carefully  selective,  although  undoubtedly  an  ad- 
mirable man,  excellent  practitioner,  and  learned  writer,  renewed 
and  added  further  strength  to  the  hypothetical  as  well  as  the 
practical  views  of  Hippocrates. 

From  this  time  but  little  of  original  force  appeared  in  medical 
literature  until  after  the  period  of  sevei-al  centuries  of  mediteval 
darkness  had  been  broken  in  upon  by  the  revival  of  learning 
and  intellectual  activity,  in  the  fifteenth  and  sixteenth  centu- 
ries. 

In  this  revival  it  was  natural  that  much  recourse  should  be,  at 
first,  had  to  the  treasures  of  the  ancients.  Plato  and  Aristotle 
divided  the  newly-revisited  realm  of  philosophy,  while  Galen,  as 
the  exponent  of  Hippocratic  doctrine,  almost  monopolized  that 
of  medicine,  until  Da  Vinci,  Telesius,  Csesalpiuus,  Campanella, 
and  Bacon  established  the  inductive  method  of  observation  and 
experiment,  most  obviously  necessary  for  advancement  in  the 
physical  sciences,  of  which  medicine  is  one, — one,  too,  which,  as 
Lord  Bacon  expressed  it,  had  been  previously  "more  labored 
than  advanced." 

C/temisi)'!/,  which  had  already  received  much  attention  from 
the  Arabians,  and  which,  under  the  fascination  of  alchemy,  had 
reached  valuable  discoveries— which,  in  fact,  in  the  hands  of 
Albertus  Magnus,  Eoger  Bacon,  Basil  Valentin,  Isaac  Hollandus, 
and  others,  had  performed  wonders,  and,  in  the  trumpetings  of 
Paracelsus,  had  made  still  more  extraordinary  pretensions — 
chemistry  was  now  ripening  into  a  great  science.     In  the  seven- 


16  INTRODUCTION, 

teenth  century  its  influence  upon  physiological  and  pathological 
theory  much  increased,  and  the  practice  of  medicine  could  not 
fail  to  be  consequently  affected.  By  Sylvius,  of  Amsterdam  and 
Leyden,  and  by  Thomas  Willis  especially,  a  school  of  CJiemiater, 
iatro-chemists,  or  chemical  physicians,  was  instituted. 

Following  the  discovery  by  Harvey  of  the  circulation  of  the 
blood,  in  the  investigations  of  Sanctorius  and  Borelli,  of  Pisa, 
mechanics  likewise  found  a  place  in  the  study  of  the  functions  of 
the  body,  in  health  and  disease.  An  latro-meclianical  school  may 
be  thus  said  to  have  existed,  to  which  the  distinguished  Senac, 
physician  to  Louis  XIV.,  among  others,  contributed,  in  a  work 
of  great  ability. 

Boerhaave,  JDrofessor  at  Leyden,  endeavored  to  combine  these, 
the  chemical  and  mechanical  modes  of  studying  the  body  and 
its  disorders,  into  an  ingenious  but  complex  ecrectic  system  of 
his  own ;  which  his  influence,  as  a  man  of  genius,  and  one  of  the 
first  of  modern  clinical  lecturers,  enabled  him  to  extend  far  and 
wide.     It  was  rather  a  dogmatical  than  an  empirical  eclecticism. 

The  latter  was  admirably  exemplified  in  the  writings  of  Sy- 
denham, who  has  been  well  called  the  modern  Hippocrates. 
Certainly  there  was  a  great  resemblance  between  the  methods 
of  the  Greek  and  English  fathers  of  medicine. 

At  the  beginning  of  the  seventeenth  century  there  grew  up, 
in  the  University  of  Halle,  two  opposing  theories  :  the  Animmn, 
or  psycho-vitalism  of  Stahl,  and  the  Solidism  and  neuro-pathol- 
ogy  of  Hoffmann.  Stahl's  doctrine  was,  in  brief,  that  the  soul 
of  man  governs  health  and  disease.  An  expectant  or  do-nothing 
practice  naturally  followed  from  such  a  view.  Hoftmann  taught 
a  less  simple  scheme  ;  but  that  part  of  it  which  seemed  to  the 
renowned  and  learned  Cullen,  the  nosologist  of  Edinburgh,  to 
be  the  most  worthy  of  his  adoption,  was  his  appreciation  of  the 
importance  of  the  nervous  system  in  the  production  of  the  phe- 
nomena of  disease. 

But  the  most  brilliant  of  the  meteors  that  have  crossed  the 
horizon  of  medical  science,  not  disappearing,  indeed,  any  of 
them,  without  leaving  some  solid  precipitate  of  knowledge,  was 
the  Sthenic  system  of  John  Brown,  of  Edinburgh,  the  pupil, 
friend,  rival,  and  enemy  of  Cullen. 

All  life,  according  to  this  bold  and  able,  although  too  reckless 
dogmatist,  depends  upon  stimulation;  all  disease  upon  too  much 
or  too  little  excitement,  causing  direct  or  indirect  debility. 
Ninety-seven  cases  of  sickness  out  of  a  hundred,  in  his  thera- 
peutics, require  stimulation  for  their  relief  or  cure.  Wonder- 
fully simple  this  !  Haller's  doctrine  of  the  irritability  of  organic 
tissues  was,  very  possibly,  its  source  ;  but  so  nearly  akin  was  it 
to  the  great  idea  of  vitalism,  dimly  seen  by  Pythagoras,  an- 
nounced by  Hippocrates,  but  lost  for  ages  until  revived  and  dis- 
torted by  Yan  Helmont  and  Stahl,  and  afterwards  rendered 
more  positive  by  J.  Hunter  and  Bichat — so  near  was  it  to  this 
imperishable  idea,  that  Brown's  theory,  thus  supported  at  once 
by  ancient  philosophy  and  modern  discovery,  had  an  unprece- 
dented influence  upon  medicine.  All  theories,  and  theorists, 
during  and  since  his  time,  unless  we  except  the  discreet  vitalism 


SYSTEMS    OF    MEDICINE.  17 

of  Barthez,  of  MontpcUier,  have  reflected  or  refracted,  with 
various  modilications,  the  Brunonian  ray. 

What  have  we  had  since,  in  fact  ?  liasori,  in  Italy,  adopted 
Brown's  pliysiological  basis,  but  considered  that  excita1)ility  and 
excitement  were  multiple,  and  unequally  distributed,  in  disordered 
states,  in  different  organs  ;  and,  moreover,  tliat  over-excitement 
was  nmch  more  frequent,  and  demanded  more  attention  in  prac- 
tice tlian  Brown  had  supposed.  Hence  arose  his  sedative  or 
"  contro-stimulant"  method,  by  large  bleeding  and  tartar  emetic  ; 
so  famous  once,  especially  in  the  treatment  of  inflammatory  afiec- 
tions  of  the  chest, 

Broussais,  in  France,  proceeding  upon  the  same  original  basis, 
saw  in  local  irritation  and  inflammatio)i,  mostly  of  the  alimentary 
canal,  the  scat  and  centre,  the  fans  et  origo  of  the  dynamic  or 
excitational  error  which  caused  all  diseases.  His  practice  varied 
from  both  Brown  and  Rasori ;  his  whole  object  being  to  calm 
and  allay  the  central  irritation  by  diluents,  demulcents,  local  de- 
pletion, and  counter  irritation,  avoiding  all  heroic  treatment. 

In  this  country,  which  can  hardly  be  said  to  have  had  a  system 
before  Rush,  that  noble  and  independent  mind  was  also  influenced 
by  the  Brunonian  radiation ;  although  a  still  different  view  of 
pathology  and  therapeutics  resulted  from  his  reflections  and  ob- 
servations. The  "  unity  of  disease"  was,  with  him,  a  favorite 
idea.  Although  his  strong  good  sense  did  not  allow  this  to  ex- 
clude from  his  appreciation  remedies  and  modes  of  treatment  not 
easily  reconciled  with  such  a  scheme.  Rush  evidently  leaned  much 
toward  the  opinion  that  all  acute  diseases  were  but  different 
"states  of  fever  ;"  for  the  mitigation  of  most  of  which  the  lancet 
was  the  potent  and  indispensable  remedy.  In  this  he  resembled 
Rasori  rather  than  Brown  or  Broussais.  Even  earlier  than  the 
universal  dissemination  of  the  teachings  of  the  latter,  the  dis- 
tinguished successor  of  Rush,  Dr.  JSTathaniel  Chapman,  of  Phila- 
delphia, claimed  and  afforded  evidence  that  he  had  first  taught  the 
theory  of  the  local  origin  of  fever,  in  irritation  of  the  alimentary 
canal ;  but  he  did  not  allow  it  to  modify  his  practice  in  the  same 
manner  as  Broussais.  A  part  of  the  practice  of  Brown  has,  under 
the  teachings  of  the  late  Dr.  Todd,  of  London,  constituted  a  medi- 
cal "  fashion"  of  the  day,  as  an  almost  undiscriminating  alcoholic 
stimidism. 

Now,  let  us  look  back.  Who  have  been  the  laTp6-iTpo(ptjTai.,  the 
great  leaders  in  medical  speculation,  the  reformers  and  deformers 
of  medical  practice?  The  list  is  not  a  long  one,  although  its  scope 
of  time  reaches  over  two  thousand  years.  Let  me  hazard  their 
enumeration.  Hippocrates,  Serapion,  Asclepiades,  Celsus,  Syl- 
vius, Harvey,  Borelli,  Sydenham,  Boerhaave,  Stahl,  Hoffmann, 
Haller,  Cullen,  Avenbrugger,  Brown,  Jenner,  Hunter,  Bell, 
Bichat,  Barthez,  Pinel,  Rasori,  Rush,  Laennec,  Broussais,  Louis, 
Liebig,  Yirchow,  Brown-S^quard. 

And  what  have  been  their  essential  ideas,  stripped  of  all  their 
complexities  and  environments?  Naturalism,  empiricism,  eclec- 
ticism, humoralism,  soUdism,  chemicism,  mechanicism,  neuro-pa- 
thologij,  stimidism,  plilogisticism,  pyrexism,  vitalism,  and  of  recent 
date  cellular  pathology  and  physiological  therapeutics.  I  leave 
2*  B 


18  INTEODUCTION. 

out  of  the  list  the  Thomsonian  extravaganza  of  thermalism,  and 
the  Hahnemannic  homoeopathism,  as,  however  serious  may  have 
been  their  detrimental 'effect  upon  the  welfare  of  the  public  at 
large,  they  have  scarcely  influenced  the  progress  or  present  status 
of  medical  science,  either  for  good  or  evil. 

Hy  natiiralisni  I  mean  dependence  upon  nature,  and  systematic 
imitation,  in  practice,  of. her  spontaneous  curative  processes.  We 
have  already  referred  to  this  as  the  leading  Hippocratic  idea.  It 
was  rejected  by  the  early  Methodists,  practically  repudiated  by 
Cullen,  and  systematically  excluded  by  Kush.  More  recently  it 
has  been  conspicuously  illustrated  and  defended  in  the  lucubra- 
tions of  Sir  John  Forbes,  following  those  of  Dr.  Bigelow,  of  Bos- 
ton, upon  "Nature  and  Art  in  Disease  ;"  to  the  former  of  which 
the  sobriquet  of  "Young  Physic  "  has  been  applied. 

"  Expectancy"  is  a  term  now  frequently  used,  to  dignify  what 
amounts  sometimes  to  absolute  inertness  of  practice  ;  upon  an 
idea,  latent  or  declared,  that  all  medicines  are  impotent,  and  that 
active  interference  with  the  self-limitations  of  disease  is  never 
justified  by  science.  This  is  but  a  reaction,  certainly  extreme, 
from  the  2^olyphar'm,acy  and  hypertherapy  of  the  past. 

Empiricism  is  strict  adhesion  to  experience  ;  the  accumulation 
of  means  of  treatment  simply  by  observation  and  experiment, 
independently  of  physio-pathological  reasoning.  Tlie  most  favor- 
able example  of  this  among  the  ancients,  was  Areteeus  ;  of  dis- 
tinguished moderns,  Sydenham,  Laennec,  and  Louis. 

Eclecticism  or  episythetism  is,  of  course,  the  selection  or  combi- 
nation of  what  is  deemed  best  in  several  methods,  as,  in  practice, 
of  means  or  measures,  some  of  which  have  been  obtained  by  mere 
observation,  and  some  from  physiological  reasoning  or  deduction. 
Celsus  afforded  the  most  beautiful  early  example  of  this  ;  it  has 
been  exemplified,  although  at  the  same  time,  somewhat  paradoxi- 
cally, derided,  in  our  own  period,  by  Trousseau,  of  Paris. 

All  of  the  other  systems  which  I  have  named  are  phases  of 
nationalism^  which  is  the  proper  antithesis  of  Empiricism. 

Solidism,  first  broached  perhaps  by  the  ancient  school  of  Ascle- 
piades,  with  its  laxum  and  strictum,  was  urged  to  its  farthest  limit 
in  the  mechanicism  of  Borelli,  and  in  the  neuro-pathology  of  Hoff- 
mann, Cullen,  and  Henle.  It  was  taught  in  Philadelphia  for 
twenty-five  years  by  Professor  N.  Chapman. 

Humoralism,  the  older  view,  which  saw  in  changes  of  the  fluids 
all  that  was  essential  in  disease,  pervaded  the  system  of  Galen, 
and  the  G-alenists  of  the  fifteenth  and  sixteenth  centuries.  The 
chemists  generally  have  had  a  natural  leaning  towards  it.  In 
this  country  it  was  represented  at  one  time  by  Dr.  Hosack,  of 
New  York.  A  very  distinguished  example  of  it  has  lately  been 
known  and  respected  in  England,  in  the  lamented  Eobert  Todd, 
of  London. 

Cfiemicism  was  boldly  inaugurated  by  Sylvius  De  Lebo,  in  the 
seventeenth  century,  but  has  received  its  ripest  contributions  in 
the  two  last  decades  ;  especially  from  Liebig  and  the  other  chemi- 
cal physiologists,  Lehmann,  Moleschott,  etc. 

Meclianicism,  as  an  exclusive  system  of  physiological  or  patho- 
logical reasoning,  was  never  permanently  established,  its  influ- 


SYSTEMS    OF    MEDICINE.  19 

ence,  as  affordino;  even  a  predominant  l)ias,  having  been  always 
confined  to  a  few  thinkers  during  a  brief  period. 

Neurn-patholngi/  has  had  a  more  important  place ;  dividing  with 
a  modified  humoralism  the  domain  of  medical  theory,  even  down 
to  the  present  hour.  We  can  never  dismiss  tlie  consideration  of 
the  nervous  centres  and  their  communicating  nerves  from  the 
study  of  tlie  human  functions,  healtliy  or  morbid.  So  that,  al- 
though it  is  decidedly  an  error  to  say,  as  some  liave  done,  that 
man  is  all  brain,  or  tliat  the  "nervous  mass"  is  the  animal,  yet 
the  nervous  system  must  be  made  prominent  in  all  medical  in- 
quiries. 

Enough  has  been  said  already  to  explain  the  nature  and  pow- 
erful influence  of  the  Brunonian  theory  of  excitement,  or  of  sthenia 
and  asthenia,  which  I  have  named  under  the  title  of  stimulism. 
It  was  one  step  towards  the  application  to  pathological  and  med- 
ical truth  of  dynamic  physiology,  that  study  of  the  forces  of 
the  living  body,  in  connection  with  the  constantly  acting  forces 
of  external  nature,  which  is  now,  or  soon,  destined  to  rule 
supremely,  not  as  excluding,  but  as  guiding  our  investigations  of 
the  chemical  and  mechanical  changes  both  of  the  solids  and  of 
the  fluids.  Life  is  not  merely  excitation  ;  but  normal  excitation 
is  one  of  the  requisite  conditions  of  the  performance  of  all  the 
functions  of  the  body,  not  even  excepting  that  of  growth  and 
development  itself ;  since  to  this  a  certain  degree  of  heat  at  least 
is  essential, 

Rasori  was,  moreover,  right  in  saying  that  excitement  is  not  a 
xmit  for  the  whole  body,  but  may  be  unequal  in  its  different  parts  ; 
and,  moreover,  that  excess  of  excitement  of  one  or  more  organs 
or  functions  is  as  frequently  present  in  acute  diseases  as  the 
reverse. 

So,  too,  Broussais  made  a  just  amendment  of  the  same  scheme, 
to  a  certain  extent,  in  noticing  the  sympathetic  and  secondary 
efi'ects  of  local  irritation ;  although  he,  as  well  as  our  Chapman, 
undoubtedly  exaggerated  the  relative  importance  of  irritation  of 
the  stomach  and  intestinal  canal. 

We  need  not  pause  for  a  moment  over  the  Stahlian  theory  of 
the  organic  soul  or  autocrateia ;  although  very  lately  a  view  much 
like  it  has  been  again  taken,  by  Laycock  and  Morell,  under  the 
cognomen  of  the  "  unconscious  soul ;"  and  in  biology,  under  that 
of  "plastidule  soul,"  by  Haeckel. 

A  recent  phase  of  revolution  in  the  scientific  basis  of  medical 
opinion,  has  been  that  which,  in  the  language  of  its  most  emi- 
nent leader,  Virchow,  of  Berlin,  we  may  designate  as  cellular 
pathology.  Associated  in  similar,  although  not  quite  identical 
views,  have  been  Prof.  Bennett,  of  Edinburgh,  and  Dr.  Addison, 
of  London. 

It  has  been  a  favorite  idea  with  the  physiologists  of  our  period 
that,  in  the  general  law  of  organic  cell-genesis,  the  fact  that 
every  living  being,  human,  animal,  and  vegetable,  springs  from  a 
globoid  germ-cell,  while  most  of  the  separate  tissues  also  have  the 
cell  for  their  first  starting  form  ;  that  in  this  we  have  the  great 
central  radical  fact  of  physio-pathology,  out  of  which  (as  in  physi- 
cal science  out  of  the  Newtonian  law  of  gravitation)  all  truth  in 


20  INTRODUCTION'. 

the  history  of  the  animal  organization,  and  tlius  in  medicine,  must 
grow.  But  Dr.  Bennett,  an  earnest  teacher  of  molecular  physi- 
ology,^ denied  that  to  the  cell  doctrine  can  be  awarded  such  a 
place  or  potency;  as  it  is  not  a  universal  law,  but  has  its  manifest 
exceptions.  Dr.  Beale,  also,  a  leading  British  authority  in  his- 
tology, insists  upon  some  essential  modifications  in  Virchow's 
theory. 

It  does  not  belong  to  me  to  discuss  this  point  here  ;  but,  as  it 
bears  largely  on  the  theory  of  medicine,  I  will  merely  say  that  if 
there  he  one  fact  or  idea  which  more  than  any  other  is  the  gravi- 
tative  centre  of  all  truth  in  physiology,  pathology,  and  medicine, 
it  is  that  of  the  peculiar  agency  and  supremacy  in  the  body  of  the 
life-force.,  and  of  its  intimate  relations  with  the  other  physical 
forces  f  of  its  being,  in  fact,  capable  of  degrees  of  life  temperature, 
like  those  of  heat  temperature,  in  the  body  as  a  whole,  and  in  its 
various  parts  and  organs  ;  of  its  manifesting  attributes  or  laws,  like 
the  other  forces  or  phases  of  impetus  and  molecular  movement  in 
nature  ;  which  must  be  much  more  patiently  and  thoroughly 
studied  than  they  have  yet  been,  before  we  can  be  said  to  under- 
stand the  human  economy,  even  so  well  as  astronomers  now  do 
the  solar  and  sidereal  systems. 

This  brings  us  towards  the  conclusion  of  our  inquiry.  "We  have 
been  examining,  in  this  brief  manner,  several  schemes  of  rational- 
ism. But  as  the  use  of  facts  and  ideas  in  the  practice  of  medicine 
is  our  standpoint,  we  must  now  ask,  Is  rationalism  available  for 
the  treatment  of  disease?  Is  physiology  perfect?  How  much 
of  it  is  positive? 

We  are  compelled  to  answer — Physiology,  and  with  it  necessarily 
pathology,  is  one  of  the  least  matured,  because  one  of  the  most 
complex  of  the  sciences.  What  would  be  said,  then,  were  a  man 
to  undertake  to  repair  a  watch,  when  he  had  never  seen  its  works 
in  motion,  and  had  n.o  proven  knowledge  of  the  mode  of  action  of 
nearly  all  its  machinery?  If  he  should  find  on  trial,  that  hanging 
it  up,  or  laying  it  down,  or  shaking  it  when  it  stopped,  or  keeping 
it  warm  or  cold,  promoted  its  good  time-keeping — very  well ;  let 
him  do  so.  But  if,  in  this  state  of  uncertain  knowledge,  he  should 
seize  and  alter,  with  fingers  or  forceps,  the  delicately  arranged  and 
complicated  wheels  and  springs,  would  not  the  chances  be  that  he 
would  do  more  mischief  than  good?  Nor  would  reasoning  about 
possible  or  probable  watches,  theories  in  chronometry,  avail  him 
much  towards  the  medication  of  the  particular  timepiece  in  his 
hands.  Yet  this  is  our  position,  as  physicians,  regarding  the 
present  relation  of  physiology  and  pathology  to  the  actual  treat- 
ment of  disease.  It  seems,  therefore,  only  a  slight  over-statement 
of  Trousseau's  that  nationalism  in  medicine  leads  only  to  absurdities. 

We  might  easily  confirm  Trousseau  by  other  authorities,  early 
and  late.  Stahl  spoke  of  the  materia  mediea  of  his  time  as  a 
"stable  full  of  otfal."  Sydenham  complains  that  practice  was 
"pestered  with  too  many  eminent  remedies. "    It  is  said  that  when 

1  Clinical  Medicine,  Introductory  Lecture. 

2  See  Grove,  Carpenter,  and  others,  on  the  Correlation  of  Physical  and  Vital  Forces  ; 
Tnman,  Foundation  for  a  New  Theory  and  Practice  of  Medicine;  Chambers,  Renewal 
of  Life,  etc. 


SYSTEMS    OF     MEDICINE.  21 

Sydenham  was  asked  by  Sir  R.  Blackmore  what  book  to  begin  his 
medical  studies  witli,  he  replied  Don  Quixote.  Biehat denounced 
the  vasjjue  theories  of  medication  prevalent  in  his  day,  and  dciclared 
that  hut  little  was  really  positive  in  our  knowledge  of  the  action  of 
remedies.  Pinel  had  so  little  conlidi'uce  in  therapeutics  that  his 
only  study  of  disease  was  for  a  naturalistic  classification:  "Given 
a  certain  malady — to  find  its  place  in  the  nosological  system." 
Laennec  considered  physiology  and  pathology  "vain  amusements 
of  the  mind."  Says  Lebert,  "We  cannot  yet,  unhappily,  con- 
struct therapeutics  on  the  basis  of  scientific  medicine  ;  and  with 
the  best  intentions  in  the  world  we  can  regard  the  greater  part 
of  its  precepts  but  as  the  result  of  emi)iricism." 

But,  some  may  exclaim,  this  is  treason  1  This  would  remove 
the  practice  of  medicine  from  science  altogether,  and  leave  it  at 
the  mercy  of  Paracelsus,  and  Cagliostro,  and  the  old  women  ! 
Not  so.  "We  have  only  to  turn  back  to  the  grand  platform  of 
Bacon,  on  which  all  modern  science  is  built,  to  see  that  to  found 
the  practice  of  medicine  on  ohservation  is  to  make  it  eminently 
scientific.  What  science  can  do  without  empirical  observation  ? 
Can  physics,  or  astronomy,  or  chemistry  V  ISTone  of  them.  How 
irrational,  then,  to  attempt  to  reason  out,  a  priori,  therapeutics, 
or  to  place  it  upon  any  other  principal  basis  than  clinical  observa- 
tion !  Blind,  uninstructed,  unsystematic  empiricism  is  a  bane 
to  society,  and  a  disgrace  to  the  human  intellect.  ^  But  scientific 
empiricism  constitutes  the  most  rational  practice  attainable, 
while  physiology  is  imperfect.  What  is  most  wanted  now,  is 
more  jjositivism  in  medicine  ;  more  exact  observation  of  clinical 
and  therapeutical  facts.  It  is  otherwise  in  most  of  the  natu- 
ral sciences.  Agassiz,  one  of  the  great  leaders  in  science,  re- 
marked that  thought  and  generalization  are  now  esipeciaWy  required 
amongst  naturalists  ;  who  are  in  danger  of  being  buried  among 
their  multitudinous  detailed  facts,  as  knights  of  old,  sometimes, 
were  borne  down  by  the  vv^eight  of  their  own  armor.  But  it  is 
not  so  in  our  science.  Medicine  needs  more  fact  and  less  theory.  I 
could  sustain  these  positions  by  argument,  by  citation,  and  by 
example  ;  but  we  have  no  room.  The  proposition  must  be  barely 
stated,  that  the  most  complete  knowledge  possible  of  a  disease 
will  never  alone  inform  us,  what  will  be  the  effect  upon  it  of  any 
remedies,  until  experience  has  put  them  to  the  test.  The  tv/o 
blades  of  the  scissors  of  practical  medicine  are,  diagnosis  and 
clinical  proof;  physiology  and  pathology  may,  perhaps,  be  com- 
pared to  the  handles ;  but  to  the  former,  rather  than  to  the  lat- 
ter, belongs  at  present  the  chief  function  of  guidance  in  our 
action.  Our  total  ignorance  of  the  modus  operandi  of  any  agent 
does  not  in  the  least  interfere  with  its  availability  in  the  treat- 
ment of  disease,  when  that  treatment  has  been  proved  to  be  suc- 
cessful. We  do  not  know — nor  does  the  chemist  require  to  know 
— why  sugar  is  sweet,  or  sulphuric  acid  sour  ;  or  why  the  latter 
will  redden  litmus,  while  an  alkali  will  render  turmeric  brown. 

1 1  advise  no  one  to  imitate  the  follies  of  Cato  the  Censor  ;  who,  while  he  forhado  his 
son  ever  employing  a  physician,  yet  dosed  his  own  wife  to  death,  attempted  to  reduce 
dislocations  by  repeating  magical  words,  and  wrote  a  book,  in  which  he  recommended 
cabbage  as  a  sovereign  remedy  for  many  diseases. 


22  INTRODUCTION. 

It  is  no  more  necessary^  although  it  would  be  interesting,  to  know 
how  bitters  improve  the  appetite,  or  iodide  of  potassium  cures 
syphilitic  rheumatism.  "We  may  use  opium  to  produce  sleep, 
or  lull  pain,  although  we  know  little  more  than  Moliere's  doctor 
— "  opium  facit  dormire,  quia  est  in  eo  virtus  dormitiva." 

It  was,  in  fact,  as  was  long  ago  observed,  "  only  after  men  had 
found  remedies,  that  they  commenced  to  reason  upon  them." 
The  most  remarkable  treasures  of  medicine  have  been  discovered 
almost  by  accident,  and  have  obtained  their  place  in  the  materia 
medica  often  against  the  protests  of  the  theorists.  Opium  is  one 
of  the  oldest  of  drugs.  Iron  is  nearly  as  ancient.  Mercury  was 
a  contribution  of  the  alchemists.  Arsenic  and  colchicum  appeared 
first  as  secret  remedies.  Iodine  (in  burnt  sponge)  and  sulphur 
were  popular  and  domestic  before  they  were  professional  medi- 
cines. And  did  not  the  French  Academy  formally  denounce  tar- 
tar emetic  ?  Did  not  all  the  schools  disbelieve  in  cinchona,  be- 
cause it  neither  sweated,  puked,  nor  purged  ?  And  Jenner, 
who  drew  the  idea  of  vaccination,  by  a  most  sagacious  induc- 
tion, from  a  popular  tradition  of  the  country,  against  what 
strong  theoretic  opposition  did  his  noble  discovery  have  to  estab- 
lish itself ! 

Nolens  volens,  then,  we  have  to  acknowledge  our  indebtedness, 
in  therapeutics,  to  empirical  observation.  But  it  is  the  vocation 
of  the  true  physician  to  make  it  scientific.  To  know  that  two 
cases  of  disease  are  really  alike,  and  not  onlj'^  apparently  so,  in 
order  for  the  application  to  them  of  the  same  remedies  ;  to  make 
accurate  comparison  of  the  virtues  of  different  modes  of  treatment, 
avoiding  the  "  post  hoc  propter  hoc  "  fallacy  ;  and  to  appreciate 
the  conditions  and  circumstances  which  modify  the  actions  of 
medicines,  as  they  do  the  course  of  diseases ;  these  are  tasks 
which  enlist  the  highest  faculties  of  ixnalysis,  as  well  as  of  obser- 
vation. 

Moreover,  medicine  is  progressive.  Even  an  incompleted  phy- 
siology may  suggest  safe  and  proper  experimentation.  For  good 
diagnosis  we  need  pathology  ;  for  pathology,  physiology  is  indis- 
pensable. We  do  not  admit,  then,  with  Laennec,  that  these 
beautiful  sciences  are  but  "vain  amusements."  We  look  for- 
ward to  the  day,  when  the  laborious  and  intelligent  culture  they 
are  now  receiving,  will  be  repaid  by  a  tenfold  harvest,  x^ractieal 
as  well  as  abstract.  The  time  may  come,  when  the  why  and 
how  of  therapeutics  may  be  largely  as  well  as  accurately  ex- 
plained. But  practical  medicine,  having  its  crying  necessities, 
cannot  wait  for  such  an  era  ;  let  it  use  its  facts,  and  not  be  mis- 
led by  false  expectations,^ 

Yet,  we  must  remember,  that  it  is  the  facts,  not  of  the  experi- 
ence of  an  individual,  which  most  of  all  is  "  experientia  fallax," 
but  of  the  aggregate  experience  of  the  whole  profession,  in  all  time, 
that  constitute  the  body  of  therapeutical  science  ;  which  should, 
as  Dr.  Todd  has  said  of  pathology,  be  reviewed  and  reconsidered 

1 "  When  there  is  no  certain  knowledge  of  a  thing,  a  mere  opinion  about  it  cannot 
discover  a  sure  remedy."  "  Medicine  ought  to  he  rational ;  but  should  draw  its  methods 
from  the  evident  cause  ;  all  the  obscure  being  removed,  not  from  the  attention  of  the  artist, 
biUfiom  the  practice  of  the  art." — Celsus,  Treatise  on  Medicine. 


SYSTEMS    OF    MEDICINE.  23 

from  time  to  time  ;  Imt  which  can  never  be  abandoned  or  rejected. 
It  is  not  well,  then,  to  call  the  great  ph3^sicians,  our  predecessors, 
as  Dr.  Bennett  has  done,  "  blind  guides."  Rather  may  we,  with 
the  late  Dr.  Alison,  believe  that  a  disagreement  between  a  newly- 
broached  pathology  and  the  practical  experience  of  all  time  is  a 
much  better  reason  for  setting  aside  the  new  pathology  than  the 
old  practice. 

Just  now  (1881)  a  form  of  medical  rationalism  is  particularly 
in  vogue,  under  the  guise  of  jjhi/siohyical  or  experimental  thera- 
peutics. Since  its  principal  reliance  is  the  application  to  the 
treatment  of  disease  of  inferences  drawn  from  the  eflfects  of 
drugs  upon  living  animals,  it  may  be  called,  without  injustice, 
the  system  of  toxico-therapy.  That  experiments  with  medicines 
upon  animals  may  have  very  consideral)le  suggestive  value,  there 
is  no  doubt.  The  error  here,  as  in  regard  to  the  kindred  subject 
of  vivisection  in  connection  with  normal  physiology,  consists  in 
overrating  its  comparative  authoritij ;  as  if  it  were,  instead  of  a 
subordinate  method,  supreme  above  all  others.  Objections  to  its 
being  permitted  to  rank  higher  than,  or  equal  to,  clinical  obser- 
vation (the  true  experimental  medicine)  are,  briefly,  these  :  first, 
the  frequent  differences  between  the  effects  of  the  same  agent 
upon  man  and  upon  animals,  as  well  as  amongst  animals  them- 
selves ;  and,  secondly,  the  great  importance  of  differences  in  the 
action  of  drugs  in  states  of  health  and  states  of  disease,  whether  of 
men  or  animals.^ 

We  may  sum  up  the  substance  of  the  foregoing  remarks,  by 
asserting  that  the  therapeutical  methods  or  principles  upon 
which  we  may  deal  with,  the  treatment  of  disease  are  essentially 
three  :^  the  natural,  hygienic,  or  expectant  ;  the  specific,  or  purely 
empirical  (including  the  tentative) ;  and  the  conditional  (including 
the  perturbative  or  alterative).  Of  the  first  two  quite  enough 
has  been  said.  Of  the  last  it  will  suffice  to  say  that  it  is  the  most 
of  all  open  to  suggestion  from  positive  physiology  and  enlight- 
ened pathology.  It  comprises  the  rational  treatment  of  diseased 
conditions  of  the  body,  for  which  no  direct  or  specific  remedy  has 
been  discovered  ;  a  part  of  medicine  of  very  great  importance, 
but  in  which  the  greatest  variation  has  necessarily  occurred  in 
the  past,  and  continues  yet  to  exist.  This  is  the  debatable 
ground,  upon  which  tournament  upon  tournament  and  crusade 
after  crusade  have  been  fought ;  the  world  at  large  looking  on 
sometunes  with  more  amusement  than  profit.  The  lesson  of 
these  petty  wars,  however — pre-indicated  clearly  by  the  old  clas- 

1  A  clear  account  of  the  former  of  these  difficulties  may  be  cited  with  advantage  from 
an  extreme  advocate  of  "  physiological  therapeutics,"  Prof.  H.  C.  Wood.  In  his  Treatise 
on  Therapeutics,  Materia  Medica,  and  Toiicology  (2d  edition,  p.  423),  while  discussing 
the  calomel  question,  this  writer  says:  "The  canine  diet  and  digestion  are  sodiiferent 
from  the  human,  that  it  is  to  be  expected  that  medicines  acting  upon  the  digestive 
apparatus  will  influence  dogs  differently  from  man."  Hence,  experimental  evidence 
must  be  "all  laid  aside  when  we  desire  to  study  the  question  as  to  the  cholagogue 
action  of  remedies  upon  man ;  and  our  conclusions  must  be  based  solely  upon  clinical 
evidence."  Without  laying  aside  any  of  the  facts  concerning  experiments  upon  ani- 
mals, we  may  unhesitatingly  apply  the  concluding  words  of  the  above  sentence  gen- 
ernl/j/ ;  by  saying  that  whatever  suggestions  or  explanations  may  be  contributed  by 
physiology  and  toxicology  to  practical  medicine,  its  final  conclimoiis  upon  the  treat- 
ment of  disease  should  always  be  based  upon  clinical  evidence  alone. 

■■i  Lordat.    See  Kenouard's  Hist,  of  Medicine. 


24  INTRODUCTION. 

sical  writers  upon  medicine — has  been  at  last  tolerably  well 
learned  :  Not  to  do  harm  when  we  are  unable  to  do  good;  the  reversal 
of  the  old  maxim,  "  melius  anceps  quam  nullum  remedium,"  be- 
cause, in  the  restoration  of  a  patient  from  disease,  the  physician 
is  not  the  only  nor  even  the  stronger  agent,  nature  being  the 
principal,  he  only  the  accessory. ^  Some  have  given  credit  for 
this  medical  gospel  to  distinguished  recent  writers,  as  Dr.  Bige- 
low  and  Sir  John  Eorbes  ;  but  they  are  revivers  of  the  doctrine 
only,  not  its  discoverers.  Hippocrates  distinctly  recognized  the 
self-limitation  of  many  diseases.  Td  Kpivd/ueva  koL  to.  KSKpifiiva  apTiug 
fii]  KLVEELv  /iTjSe  veuTepoTToieEiv,  iii]Te  (pap/xaKETjai  p.rjr''  alloiULv  ipEdLGfioiaiv^ 
alV  kav.^  So  also  did  Asclepiades,  notwithstanding  the  protest 
of  his  sect  against  Hippocratism,  when  he  said  that  the  best  cure 
for  a  fever  is  the  fever  itself.^  So  did  Sydenham*  and  others  who 
wrote  long  ago.  We  may,  perhaps,  safely  divide  the  progress 
of  historical  medicine  (as  to  its  predominant  tendencies)  into 
three  great  periods.  1.  Indefinite^  often  heroic,  always  venture- 
some tentative  practice  ;  lasting  from  archaic  times  down  to  near 
themiddle  of  our  nineteenth  century.  2.  Under  a  somewhat  de- 
spairing reaction  from  this  has  come  the  era  of  medical  scephasm, 
minimism^  expectancy;  which  qualities  characterize  much  of  the 
ordinary  practice  of  to-day.  3.  Following  this,  it  may  be  hoped, 
will  yet  come  the  scientific  medicine  of  the  future:  definite  in  its 
facts,  clear  in  its  indications,  positive  in  its  therapeutic  measures  ; 
in  accordance  with  a  well-ascertained  knowledge  of  the  body,  in 
health  and  disease. 

And  now,  although  Dr.  Bennett,  of  Edinburgh,  predicted  the 
"approaching  downfall  of  empirical  practice,"  yet  his  co-laborer. 
Dr.  Todd,  of  London,  urged  in  his  last  words  the  importance  of 
its  support  in  clinical  research  ;  and  the  philosophic  medical  his- 
torian, Renouard,  seconding  the  eflforts  of  Louis,  the  founder  of 
the  numerical  method,  andlfollowed  by  the  lamented  Niemeyer, 
Sir  W.  Jenner,^  and  others,  has  foretold  the  coming  triumph  of 
rational  empiricism  or  inductive  medicine.  We  may  well  believe 
that  this  prophecy  will  yet  be  fulfilled. 

iChomel.  2  Aphorism  20,  Section  1st.  ^Cselius  Aurelianus. 

4"  To  imagine  that  nature  always  needs  the  aid  of  art  is  an  error,  and  an  unlearned 
error,  too." 

5  "  It  is  to  the  experience  of  the  mass  of  the  profession  that  we  look  for  the  final 
establishment  of  doctrine,  and  of  rules  of  practice."— fAe  Practical  Medicine  of  To-Bay, 
18G9,  p.  7. 


PART  I. 
PRINCIPLES    OF    MEDICINE. 


SECTION"  I. 

GENERAL  PATHOLOGY. 

DISEASE  may  be  defined  as  a  perversion  either  of  the  functions 
or  of  the  structure  of  the  body  or  of  any  of  its  parts.     It  is, 
in  other  words,  a  deviation  from  the  normal  physiological  state  or 
action  of  the  organism,  under  the  disturbing  influence  of  morbid 
causes. 
The  seat  of  disease  may  be 
In  the  constitution:  e.  g.,  secondary  syphilis  ;  scrofula. 
In  special  tissues:  e.  fir.,  mollities  ossium. 
In  particular  apparatus:  e.  g.,  dyspepsia  ;  neuralgia. 
In  individual  organs  :  e.g.,  pleurisy;  cirrhosis;  hydatids. 
In  the  blood:  e.  (/.,  anaemia  ;  scorbutus  ;  typhus. 
Of  course  disease  may  be,  and  generally  is,  not  limited  to  what 
is  to  be  regarded  as  its  principal  or  original  seat.     For  example, 
in  cholera,  while  its  cause,  no  doubt,  acts  first  upon  the  blood, 
the  ganglionic  system  also  is  affected,  as  well  as  the  stomach  and 
bowels,  etc. 

Morbid  states  of  the  system : — 
Eever ; 
Toxaemia ; 
Anremia  ; 
Plethora ; 
Cachexia ; 
Depression ; 
Exhaustion. 
Morbid  states  of  organs : — 
Hypersemia ; 
Hyperfesthesia  ; 
Hypertrophy ; 
Inflammation  ; 
Atony  ;  Exhaustion  ; 
Atrophy  ; 
Degeneration. 
Of  the  above,  the  most  important  general  or  systemic  morbid 
3  25 


26  GEXERALPATHOL,OGY, 

states  may  be  included  under  fever,  toxaemia,  and  cachexia ;  con- 
stituting a  sort  of  "■  tripod  "  of  systemic  disease. 

A  similar  tripod  of  the  most  frequent  and  important  local  dis- 
orders may  be  established,  of  irritation,  inflammation,  and 
atrophy. 

GEWEKAL  PATHOLOGY  OF  AFFECTIONS  OF  THE  SYSTEM. 
FEVER. 

In  using  the  term  fever,  as  applied  to  a  morbid  state  of  the 
system,  we  must  remember  that  the  same  word  is  also  used  as  a 
part  of  the  designation  of  several  complex  diseases:  as  typhus  fever, 
yellow  fever,  remittent  fever,  etc.  This  double  use  of  the  word  is 
unfortunate,  but  cannot  now  be  avoided. 

Symptoms  of  Fever. — Increased  heat  of  the  whole  body; 

Dryness  of  the  skin,  mouth,  etc.; 

Diminution  in  hulk  of  the  excretions ; 

Muscular  debility ; 

Frequency  of  the  pulse ; 

Functional  disturbance  of  stomach,  brain,  etc. 

Heat  is  the  most  essential  characteristic  of  the  febrile  state, 
having  given  name  to  it  in  all  languages. 

Notwithstanding  the  scantiness  in  quantity  of  the  stools,  urine, 
and  perspiration  in  fever,  it  has  been  shown  by  Virchow,  Yogel, 
Bocker,  Parkes,  Jenner,  and  Plammond,  that  the  actual  amount 
of  solid  matter  excreted^  especially  by  the  kidneys,  is  generally  in- 
creased. We  have,  in  the  heavy,  offensive  odor  of  the  breath,  evi- 
dence that  it,  too,  contains  an  excessive  amount  of  decomposing 
organic  material.  It  is  highly  probable,  also,  that  much  excremen- 
titious  matter  is,  during  fever,  retained  in  the  blood.  It  has  been 
observed,  that  if  a  local  inflammation,  as  pneumonia,  occurs  during 
the  febrile  attack,  the  excess  of  secreted  solids  disappears  until  the 
inflammation  has  passed.  Dr.  C.  Anton  Errald,  as  well  as  Ley- 
den  and  Frankei,^  upon  the  basis  of  numerous  careful  observations, 
asserts  that  the  amount  of  carbonic  acid  excreted  is  always  in- 
creased during  fever.^  Ammoniacal  matter,  also,  is  present  in  the 
breath  exhaled,  in  sufficient  amount  to  form  (Fothergill)  crystals 
of  chloride  of  ammonium  when  a  glass  slide  moistened  with  hydro- 
chloric acid  is  held  under  the  nostrils.  Brattlcr^  ascertained  a 
close  correspondence  between  the  amount  of  urea  passed  in  the 
urine  and  the  temperature  ;  "the  greater  the  amount  of  urea, 
the  greater  the  temperature. " 

When  perspiration  is  absent,  there  is  evidently,  also,  a  dimin- 
ished loss  of  heat  from  the  body,  which,  of  course,  promotes  its 
accumulation.     This  is  very  important. 

This  increase  of  the  disintegration  of  the  substance  of  the  body 
is,  at  present,  one  of  the  most  prominent  and  interesting  phenom- 
ena connected  with  the  pathology  of  fever.  The  whole  subject, 
however,  is  surrounded  by  obscurity,  notwithstanding  the  fact  that 

1  Cen trail )latt,  f.  d.  Md.  Wissenshaft,  Sept.  28,  1878. 

2  Philadelphia  Medical  Times,  September  20,  1873;  translated  from  Archiv  fUr 
Anatomie,  Physiologie,  etc. 

^Uuoted  by  Murchison,  in  his  work  on  Fevers. 


TOXiEMIA.  27 

the  symptomf;  and  aspects  of  the  febrile  state  have  been  familiar 
ever  since  man  became  a  prey  to  disease. 

On  the  basis  of  the  facts  observed  and  scrutinized  at  the  present 
tinic!,  I  think  we  may  venture  to  throw  out  a  comprehensive 
theory  of  fever.  Thus — its  ess(!ntial  phenomenon  is  increased 
heat  of  the  body  ;  this  bein<i;  produced  by  excessive  tissue-meta- 
morphosis,^  under  an  abnormal  "' tinision-condition"  (Virchow) 
of  the  Ganglionic  nerve-centres,  which  abnormal  condition  is  the 
result  (Addison)  of  either,  1,  corpuscular  toxaemia,  or  2,  plasmic 
toxaimia,  or  3  (Campbell  and  Miiller),  sympathetic  irritation  from 
local  inflammation.  The  hypothesis  of  the  existence  of  a  "heat 
centre,"  and  a  "heat-inhibitory  centre"  in  the  cerebro-spinal 
axis,  which  has  found  favor  with  Dr.  II.  C.  Wood,  in  his  elaborate 
monograph  on  Fever,-  is  too  uuphysiological  (although  in  keeping 
with  many  other  theories  of  the  day)  to  be  accepted  without 
much  more  and  better  evidence  than  has  yet  been  brought  for- 
ward to  sustain  it. 

A  pathological  classification  of  fevers,  convenient  for  some  pur- 
poses, is,  into  irritative,  paroxysmal,  and  toxaemic  fevers.  The 
gungllonic  nervous  system  would  seem  to  be  most  involved  in  the 
first,  or  phlegmasiai  (pneumonia,  pleurisy,  etc.);  the  sjnnal  system 
in  the  second  (intermittent  and  remittent  fevers';  the  whole  ner- 
vous system,  and  prominently  the  brain,  in  the  third,  as  typhus, 
typhoid,  and  "spotted"  or  cerebro-spinal  fever.  Dr.  AUbutt 
compares  intermittent  fever,  as  a  periodic  discharge  of  tension 
with  disengagement  of  heat,  to  epilepsy,  which  is  a  periodic  dis- 
charge of  tension  in  the  form  of  motionJ 

TOX^anA. 

Toxaemia,  more  properly  toxicohcemia  (from  to^ikov,  poison,  and 
alfia,  blood),  is  a  term  used  to  indicate  poisoning  of  the  blood. 

After  all  the  long  and  reiterated  disputes  between  the  advocates 
of  the  exclusive  solidist  and  himioral  pathologies,  it  has  become  a 
matter  of  general  recognition  that  both  the  fluids  and  the  solids  are 
involved  in  almost  every  disease— their  mutual  interdependence 
making  the  contrary  impossible. 

Certain  diseases,  however,  more  than  others,  are  believed,  upon 
the  strongest  evidence,  to  depend  upon  a  chemical  and  functional 
change  in^the  bloody  to  which  the  name  of  toxsemia  is  applied. 

Toxaemia  may  originate  :  1.  By  the  introduction  into  the  blood 
of  morbid  -poisons  from  without ;  as  in  syphilis,  small-pox,  remit- 
tent fever,  etc.  2.  By  morbid  alteration  from  processes  occurring 
in  the  blood  itself.  3.  By  absorption  of  poisonous  material,  by  the 
vessels,  from  diseased  parts  of  the  body  ;  as  in  purulent  infection 
after  wounds,  etc,  4.  By  the  non-excretion,  and  consequent  ac- 
cumulation in  the  blood,  of  post-organic  or  excrementitious  sub- 

iThe  directness  of  the  relation  in  the  body  between  temperature  and  oxidation  is 
well  illustrated  in  the  researches  of  Prof.  H.  C.  Wood.  Jr.  (Am.  Journal  of  Med.  Sci- 
ences, July,  1871),  upon  the  action  of  nitrite  of  amyl.  This  substance,  whose  influence 
in  retarding  oxidation  can  be  demonstrated  in  a  jar  containiuR  phosphorus,  exhibits  a 
remarkable  power  of  lowering  the  temperature  of  animals  to  which  it  is  administered. 

2  Washington  and  Philadelphia,  1881. 

»Brit.  and  For.  Medico-Chirurg.  Review,  July,  1870,  p.  155. 


28  GENERAL     PATHOLOGY. 

stances,  which,  by  their  own  properties,  or  by  the  chemical 
changes  they  undergo,  prove  injurious  to  the  system.  Obstruct- 
ive jaundice  and  uraemia  afford  the  best  examples  of  this  last 
occurrence. 

1.  All  of  the  zymotic  or  entheiic  diseases  (e.  g.,  exanthemata, 
yellow  fever,  diphtheria)  have  their  origin  explained  by  the  first 
of  the  above  modes  of  blood-poisoning. 

Yet,  our  knowledge  of  the  very  existence  of  several  of  these 
"  morbid  poisons"  is  inferential  only.  Our  idea  of  their  nature  is 
conjectural ;  and  our  reasonings  upon  their  mode  of  action  upon 
the  blood  and  system  at  large  are  entirely  speculative. 

Some  facts,  however  (see  Simon^s  Lectures  on  Pathology),  are 
well  deserving  of  notice. 

o.  The  effects  of  these  poisons,  when  introduced  into  the  body, 
are  both  local  and  constitutional  symptoms.  The  constitutional 
symptoms,  which  begin  the  attack,  are  nearly  alike  for  them  all ; 
the  local  symptoms  ?ixe  peculiar  for  each  one. 

h.  The  small-pox  virus  is  the  most  readily  studied  of  all  of  these 
causes.  The  material  is,  if  not  volatile,  at  least  portable  by  the 
air,^  as  it  acts  often  through  considerable  distances;  and  it  is 
soluble,  because  it  infects,  sometimes,  the  foetus  in  utero,  which 
has  no  communication  of  fluids  with  the  mother,  except  by  pla- 
cental endosmosis.  The  poison  of  primary  syphilis  is  not  thus 
transmissible,  although  it  is  directly  contag"ious  by  inoculation ; 
that  of  secondary  syphilis  is  not'^  usually  contagious,  but  is  trans- 
missible by  descent. 

c.  One  attack  of  small-pox,  scarlatina,  measles,  whooping-cough, 
usually  gives  immunity  for  the  rest  of  a  lifetime.  It  may,  from 
this,  be  argued  that  besides  the  materies  morbi  or  causative  matter, 
another  material  must  exist  in  the  blood  of  the  susceptible  person, 
which  combines  with  the  former  (thus  producing  the  disease)^  and 
which  is  exhaustible.'^  (Illustration :  the  saturation  of  a  carbonated 
alkali  by  an  acid ;  after  a  certain  portion  of  the  latter  has  been 
added,  it  will  cease  to  effervesce  with  any  subsequent  addition  of  the 
same. )  Paget  believes  that  the  change  effected  occurs  in  the  solid 
structures  of  the  body. 

Vaccination  can  be  best  explained  upon  this  view.  Just  as 
more  than  one  acid  will  neutralize  potassa  or  soda,  etc.,  so  that 
after  it  has  been  saturated  with  sulphuric  acid  it  will  not  react 
with  nitric  —so  the  virus  of  the  vaccine  disease  appears  capable  of 
saturating  and  exhausting  that  material  in  the  body,  the  presence  of 
which  constitutes  the  susceptibility  to  variola. 

No  such  immunity  after  a  single  attack  is  found  to  exist  in  the 
case  of  the  miasmatic  fevers  (remittent  intermittent).  That  ele- 
ment in  the  blood  for  which  their  morbid  poison  has  aflinity  is. 


1  Chauveau's  experiments,  if  accepted  as  entirely  exact,  disprove  the  volatility  of  the 
■virus,  and  show  it  to  be  composed  of  particles. 

2  Recent  experiments  have  occasioned  doubt  as  to  the  correctness  of  this  commonly- 
accepted  statement.  Indeed  it  appears  to  be  proved  by  Lee,  Waller,  Pelizarri,  and 
others,  that  occasional  transfer  of  constitutional  syphilis  by  inoculation  is  possible. 
See  Lectures  on  Surgical  Path<ilogy,  by  Henry  Lee,  F.  R.  S.,  1870. 

3  Reflection  will  show  that  there  is  no  real  incompatibility  between  this  theory  and 
that  of  zynioHs,  to  be  mentioned  presently.  We  have  not  space,  however,  for  the  fur- 
ther discussion  of  so  .speculative  a  subject. 


TOXiEMIA.  29 

therefore,  not  exhaustible.  Several  reasons  exist  for  conjecturing 
this  element  to  be  the  red  ccyrpuscJcfi  themselves. 

Of  the  different  hypotheses  propounded  in  regard  to  the  modus 
operandi  of  zymotic  or  enthetic  (epidemic,  endemic,  infectious,  or 
contagious)  causes  upon  the  blood,  that  which  has  best  stood  its 
ground  is  that  of  catalysis,  or  continuous  molecular  action. 

Liebig  tirst  urged  this  theory,  upon  the  analogy  between  the 
action  of  yeast  in  producing  fermentation,  and  that  of  a  virus,  as 
of  small-pox,  in  producing  its  eflects  upon  the  system,  tlirough  the 
blood.  It  is  true,  that  the  blood  does  not  ferment;  the  action  is 
therefore  not  sitinlai\  but  analogous.  Chemical  action  of  a  certain 
kind,  going  on  in  the  particles  of  the  yeast,  or  of  a  virus,  is  by 
their  contact  with  another  substance,  communicated  to  or  insti- 
gated among  the  particles  of  the  latter.  A  mechanical  analogy  to 
illustrate  this  is  the  setting  in  motion  of  one  cog-wheel  by  another. 
A  physical  illustration,  less  remote,  is  that  of  the  extension  of 
fire  from  a  burning  body  to  other  combustibles  near  it. 

Davaine,  Hallier,  Oertel,  Salisbur}^,  Obermeier,  and  others  have 
asserted  the  discovery  of  special  organic  forms,  chiefly  of  micro- 
scopic fungous  vegetation,  in  the  blood  and  other  fluids  of  patients 
suffering  with  carbuncle,  cholera,  intermittent  fever,  syphilis, 
gonorrhoea,  etc.  The  importance  of  these  forms  in  the  causa- 
tion of  disease  is  denied  positively  by  Thudichum  among  medical 
authorities,  and  by  Berkeley,  a  distinguished  naturalist.  The 
question  is  certainly  yet  sub  judice.^ 

2.  Toxaemia  from  spontaneous  changes  in  the  Mood  itself,  under 
causes  or  conditions  which  do  not  affect  the  solid  structures  of 
the  body,  if  it  occur,  must  be  rare.  Heat-stroke  may  be,  in  part, 
an  example  ;  that  is,  the  dangerous  or  fatal  effect  of  extreme 
heat,  with  exhaustion,  away  from  the  direct  influence  of-  the 
rays  of  the  sun.  Here  the  blood  probably  undergoes  a  chemical 
change  which  renders  it  unfit  to  vitalize  the  nerve-centres  and 
other  organs.^ 

Perhaps  pygemia,  ichorsBmia,  or  septsemia^  (pus-forming  blood 
— contaminated  blood — blood-decomposition),  as  nearly  the  same 
affection  is  called  hj  different  authors,  may  be  supposed  to  occur 
sometimes  spontaneously.  Much  more  often,  however,  such  an 
affection  is  ascribed  to  the  next  mode  of  causation. 

3.  Absorption  of  deleterious  material,  by  the  blood-vessels  or 
lymphatics,  from  parts  of  the  body  in  a  state  of  disease,  may 
cause  purulent  infection,  or  pysemia. 

Absorption  of  pus  (containing  pus-cells)  is  unlikely  to  occur 
without  a  solution  of  continuity  in  the  vessels.  But  in  arteritis, 
ov  phlebitis,  suppuration  of  an  artery  or  vein  may  introduce  pus 
into  the  blood. 

In  the  greater  number  of  cases  it  is  not  pus,  but  an  unhealthy 
material  of  a  less  definite  nature,  which  contaminates  the  blood 

iSoe  an  article  upon  it  by  H.  C.  Wood,  Jr.,  M.  D.,  Am.  Journ.  of  Med.  Sciences, 
October,  1868. 

2  The  experiments  of  Wood  and  others,  which  have  been  thought  to  show  the  ab- 
sence of  a  fatal  blood-change  in  heat-stroke,  do  not  appear  to  me  to  establish  that 
conclusion.  Blood-corpuscles,  nerve-cells,  and  muscle-elements  are  all  disfunctioned 
by  high  temperature. 

^  SaprcBinia,  used  by  a  few  authors,  has  almost  the  same  signification. 

3* 


30  GENERAL,    PATHOLOGY. 

by  its  absorption.  This  may  take  place  after  wounds  or  surgical 
operations — from  the  womb  in  the  puerperal  state,  etc.  Pysemia 
is  attended  by  great  prostration,  rapid  pulse,  copious  perspira- 
tions, low  delirium,  and  the  depositing  of  pus  and  formation  of 
abscesses  in  different  parts  of  the  body.  It  very  often  begins 
with  a  chill  (see  Pyeemia,  in  Part  II.),  This  is  not  the  place  to 
discuss  the  difficult  question,  whether  minute  organisms^  or  their 
spores  (called  disease  germs,  bacteria,  bacilli,  micrococci,  raicro- 
zymes,  microbes,  etc.),  are  necessary  to  the  process  of  suppuration, 
ordinary  or  specific.  Many  facts  support  the  view  maintained 
by  Dr.  B.  W,  Richardson,  that  at  least  one  kind  of  organic  (post- 
organic)  material,  "sepsin,"and  most  probably  more  than  one 
chemical  substance  of  similar  origin,  may  produce  septcpmia  or 
scqyrcemia,  if  not  suppuration  and  pyaemia,  without  any  germs  or 
organisms  being  present.  On  the  other  hand,  the  following  is  a 
recent  expression^  of  an  able  and  careful  investigator,  Surgeon 
G.  M.  Sternberg,  U.S.A.  : 

"In  the  light  of  what  we  already  know,  it  seems  very  probable 
that  puerperal  fever,  hospital  gangrene,  and  the  various  forms 
of  septic&emia  known  to  physicians  and  surgeons,  result  from  the 
development  of  pathogenic  varieties  of  harmless  and  widely-dis- 
tributed species  of  micrococci,  as  the  result  of  especially  favorable 
surroundings,  such  as  are  found  in  the  lochial  discharges  of  a 
puerperal  woman  or  in  the  secretions  from  the  surface  of  wounds 
in  a  crowded  and  illy-ventilated  hospital  ward.  Just  as  differ- 
ences in  resisting-power  to  experimental  septicaemia  are  exhibited 
by  different  species  of  animals,  so,  doubtless,  individual  differ- 
ences exist  in  man,  especially  as  the  result  of  lowered  vitality.'''' 

4.  Toxaemia  from  non-elimination  of  the  secretions  may  fol- 
low, of  course,  upon  prolonged  constipation,  obstruction  of  the 
biliary  duct,  inaction  of  the  liver,  or  suppression  of  the  action 
of  the  skin  and  kidneys. 

Effort  is  made  (according  to  the  adaptations  of  nature),  when 
one  emunctory  fails  to  act,  to  carry  out  its  excreta  by  other  chan- 
nels. Especially  do  the  skin  and  kidneys  act  thus  vicariously  for 
each  other. 

When  the  blood  is  in  no  way  rid  of  those  effete  particles  which 
should  make  the  solids  of  the  urine.,  the  resulting  condition  is 
called  ursemia  or  urinffimia.  Its  symptoms  are  pain  in  the  head, 
dulness  of  sight  and  hearing,  vertigo,  nausea,  and  vomiting ; 
ending,  unless  relieved,  in  convulsions,  coma,  and  death.  Preg- 
nant women  sometimes  have  urmmic  convulsions  (C.  Braun),  from 
foetal  pressure  obstructing  the  renal  circulation. 

The  term  cholsemia  is  less  used,  though  quite  as  justifiable  as 
ursemia.  It  means  retention  in  the  blood  of  the  excrementitious 
matter  of  the  bile,  from  inaction  of  the  liver  or  obstruction  of  its 
duct.  Cholestersemia  is  a  term  preferred  by  Dr.  A.  Flint,  Jr., 
who  asserts  cholesterin  to  be  the  excretory  ingredient  of  bile. 
Eleischl  has  shown  that  the  lymphatic  vessels  may  reabsorb  bile 
and  convey  it  into  the  blood. 

Jaundice  is  of  two  origins  :  1,  obstruction  of  the  biliary  ducts, 

1  National  Board  of  Health  Bulletin,  April  30, 1881. 


ANiEMIA.  31 

with  reabsorption  of  bile  into  the  blood  ;  2,  suppression  of  the 
secretion  of  the  liver.  (A  third  is  possible  —  perhaps  present  in 
the  janndice  of  infancy  ;  viz.,  excessive  formation,  of  yellow 
pigment  in  the  blood,  and  its  deposit  in  the  skin,  etc.,  without 
disorder  of  the  liver.) 

In  jaundice  from  ol)struetion  and  real)sorption,  the  symptoms 
are  milder  and  the  state  less  dangerous  than  in  that  from  sup- 
pression of  the  action  of  the  liver.  Severe  and  even  fatal  disease 
of  the  liver  may  occur,  however,  witbout  jaundice. 

Dr.  Ilarloy  has  shown  that  the  diagnosis  between  these  two 
forms  of  jaundice  may  be  made,  on  analysis  of  the  urine,  by  find- 
ing the  coloring  matter  of  the  bile  always  in  the  urine  in  botli,  but 
the  biliary  acids  only  in  the  ohstrnctive  form. 

Slight  and  transient  chola-mia  is,  no  doubt,  common.  Although 
the  term  "biliousness"  is  much  abused,  it  is  not  always  quite  a 
misnomer.  As  signs  of  the  condition  mentioned,  we  find  nausea, 
bitter  taste  in  the  mouth,  constipation,  and  dizziness,  with  yellow- 
ness of  the  tongue,  conjunctiva,  and  skin. 

Acetonaemia  and  lipsemia  are  referred  to  by  authors  (Kuss- 
maul,^  Cyr,"  Balthazar  Foster,^  Sanders,^  Hamilton,'^  Starr''),  as 
both  occurring  in  cases  of  advanced  diabetes  mellitus,  especially 
when  terminated  by  sudden  death.  Acetone  is  one  of  the  pro- 
ducts of  a  fermentative  change  in  glucose  (grape-sugar,  diabetic 
sugar).  It  stupefies  animals,  when  given  to  them,  with  an  efl'ect 
somewhat  between  that  of  alcohol  and  that  of  ether.  It  has 
been  detected  in  the  blood,  urine,  and  breath  of  diabetic  patients, 
but  in  such  small  quantity  as  to  make  it  doubtful  whether  its 
accumulation  can  account  for  sudden  death. 

Lipccmia  is  an  excess  of  fatty  matter  in  the  blood.  It  gives 
that  liquid  a  milky  appearance,  which  ether  will  remove  ;  and 
the  microscope  may  show  the  presence  of  oil-globules.  Fatty 
emboli  may  form,  and,  by  obstructing  arterial  trunks,  may  inter- 
fere with  the  functions  of  the  organs  which  they  supply.  When 
this  occurs  in  the  pulmonary  artery  or  its  branches,  anoxcemia 
(deficiency  of  oxygen  in  the  blood)  may  result,  with  accumula- 
tion of  carbonic  acid  in  the  blood  and  fatal  coma.  Uncertainty 
remains,  however,  in  regard  to  the  share  which  such  a  series  of 
changes  may  have  in  producing  sudden  death. 

AN..EMIA. 

Ansemia  [spancemia^  hyclrce^nia)  is  the  common  term  indicating 
poverty  of  the  blood.  The  density  of  that  liquid  is  diminished, 
and  there  is  a  deficiency  in  the  number  of  the  red  corpuscles. 
Hayem  and  Malassez  also  assert  diminution  of  size,  change  of 
form,  and  reduction  of  color  in  the  red  corpuscles.  Their  amount 
of  hoemoglobin  may  be  lessened  by  more  than  three-fourths  of  the 
normal  proportion.  In  marked  cases  of  ansemia  one  hundred 
red  corpuscles  may  occupy  no  more  space  than  seventy-five  cor- 
puscles taken  from  healthy  blood. 

1  Deutsches  Archiv.  f.  Klin.  Med.,  August,  1874. 

2  Archives  Gen.  de  Medecdne,  December,  1877,  and  January,  187S. 

3  Brit.  Med.  Jour.,  January  19, 1878.  *  Edin.  Med.  Jour.,  .Tuly,  1879. 
5  Edin.  Med.  Jour.,  July,  1879.  6  n.  Y.  Med.  Rec.,  May  1, 1880. 


32  GENERAL    PATHOLOGY. 

The  deficiency  in  number  and  healthy  character  of  the  cor- 
puscles may  be  conceived  as  capable  of  production  in  either  of 
two  ways  :  anaBmatosis,  or  imperfect  formation  and  development 
of  blood-elements  ;  or  haemophthisis,  i.e.,  their  degeneration  and 
destruction  after  they  have  been  formed. 

Exhausting  hemorrhages  or  discharges,  severe  attacks  or  long 
continuance  of  disease,  insufficiency  of  food,  etc.,  may  cause  the 
ansemic  condition.  Sometimes  it  occurs  without  such  cognizable 
causes,  being  then  designated  as  idiopathic  or  progressive  per- 
nicious ansemia.    (See  Part  II.) 

Anaemia  is  shown  by  paleness  (sometimes  with  occasional 
flushes)  of  the  face,  even  of  the  lips  and  tongue,  as  well  as  of 
the  hands  ;  debility  ;  feebleness  and  excitability  of  the  pulse  ; 
frequently  palpitation  of  the  heart  and  a  bellows  m,urmu7\  audible 
especially  near  the  base  of  the  heart,  to  be  carefully  distinguished 
from  the  valvular  murmurs  of  organic  disease.  Nervousness  and 
neuralgic  pains  are  also  very  common  in  the  anaemic. 

Chlorosis,  althougli  sometimes  separated  from  anaemia,  is  gen- 
erally associated  with  it,  occurring  in  young  females.  The  name 
is  given  on  account  of  the  peculiar  sallowness  of  the  complexion. 
Perverted  appetite,  as  for  charcoal,  slate-pencils ,  etc. ,  is  one  of  its 
occasional  symptoms.     (See  Part  11.) 

Ischaeinia  is  an  interruption  or  embarrassment  of  the  circula- 
tion of  the  blood  in  any  part  of  the  body.  (Sometimes,  also, 
this  term  has  been  applied  to  the  suppression  of  a  habitual  dis- 
charge of  blood,  as  of  the  menses,  nose-bleeding,  or  bleeding 
from  hemorrhoids. ) 

Plethora  involves  an  excess  in  the  density  of  the  blood,  and  in 
the  number  of  its  red  corpuscles  ;  the  opposite  to  anaemia.  It  is 
shown  by  a  high  color  of  the  face,  distension  of  the  blood-vessels,  a 
full,  strong,  but  rather  slow  pulse,  and  general  roundness  of  the 
figure.  It  may  exist  without  actual  deviation  from  health  ;  but 
the  plethoric  are  especially  liable  to  acute  inflammations,  active 
congestions,  and  hemorrhages. 

CACHEXIA. 

Cachexia  (from  namg,  bad,  and  ff/?,  habit)  is  usually  understood 
to  mean  a  depraved  habit  of  system  ;  an  error  of  development  and 
nutrition  affecting  the  general  state  of  the  blood  and  organs  with 
perversion. 

There  is,  at  the  same  time,  no  good  reason  why  we  should  not 
speak  of  local  as  well  as  general  cachexiae  ;  although  this  has  not 
been  usual. 

Melanoeynia,  Addison'' s  disease,  and  leucocythcemia,  may  be  re- 
garded as  cachexiae. 

Melanffimia  is  the  name  given  (Frerichs)  to  a  state  of  the  blood 
common  in  severe  malarial  fevers,  in  which  the  coloring  matter 
(pigment)  escapes  from  the  corpuscles,  and  is  deposited  in  the 
liver  and  other  organs. 

Morbus  Addisonii,  Addison's  disease,  is  a  rare  constitutional 
malady,  in  which  anaemia  coincides  with  bronzing  of  the  skin, 
disease  of  the  suprarenal  capsules,  and  progressive  debilit}', 
usually  ending  in  death.    The  capsular  disease  is  not  shown  by 


CACITRXTA.  33 

any  definite  local  symptoms  during  life  ;  and  its  frequent  connec- 
tion with  the  aickexid  has  not  been  explained. 

Leucocytheemia  (leuktemia)  has  been,  after  Virchow  and  Ben- 
nett, recoo;nized  as  a  condition  in  which  the  number  of  colorless 
corpuscles  in  the  blood  is  increased;  sometimes  numbering  one  to 
four,  three,  or  two,  instead  of  one  to  fifty  or  more  (sometimes 
four  or  live  hundred),  of  the  red  corpuscles.  Diminution  in  the 
number  of  red  corpuscles  also  occurs.  This,  of  course,  can  be 
ascertained  only  by  means  of  the  microscope. 

Enlargement  of' the  liver,  and  still  more  of  the  spleen,  and 
disease  in  these  organs  as  well  as  in  the  thyroid  and  lymphatic 
glands,  and  sometimes  of  the  bones,  are  found  to  attend  this 
disorder.  It  most  frequently  affects  men.  Its  symptoms  are, 
pallor,  emaciation,  diarrha-a,  epistaxis  (bleeding  from  the  nose), 
or  other  hemorrhages,  and  dropsy.     (See  Part  II.) 

Pseudo-leukffimia,  or  Hodgkin's  disease  [aclenie  or  lymphade- 
nosis), is  marked  by  general  enlargement  of  the  lymphatic  glands, 
and  most  commonly  also  of  the  spleen,  with  aneemia  and  debility. 
It  is  a  slowly  progressive  cachexia,  terminating,  after  a  duration 
of  months  or  years,  in  death  by  asthenia ;  unless  a  fatal  result 
occur  sooner  from  obstruction  to  vital  functions  by  the  enlarged 
glands.  It  differs  from  leukaemia  in  that  the  colorless  corpuscles 
of  the  blood  are  not  absolutely  increased  in  number,  but  only 
relatively  to  the  red  corpuscles. 

Much  more  frequent,  and  therefore  important,  the  most  com- 
mon and  destructive  of  all  cachectic  affections,  is  tuberculosis. 

While  diverse  opinions  exist  as  to  the  essential  nature  of 
tubei'cle  and  its  origin,  there  is  a  general  agreement  among 
pathologists  and  clinical  observers  upon  many  of  the  following 
points : — 

1.  Tuberculosis  and  Serofulosis  are  identical  as  a  diathesis.^ 
The  term  scrofula  is  generally  applied  to  certain  slow  inflamma- 
tions, abscesses,  ulcerations,  and  other  disorders  of  the  skin, 
mucous  membranes,  glands,  and  bones,  which  occur  especially  in 
young  persons,  and  are  characterized  by  the  moderate  degree  of 
vascular  excitement  attending  them,  with  the  great  obstinacy  or 
chronicity  of  their  career.  In  many  cases,  also,  of  external  scrof- 
ula, particularly  m  the  glands,  a  deposit  of  curd-like  or  cheesy 
material  is  found. 

Through  all  the  recent  discussions  as  to  what  constitutes  tuber- 
cle, it  has  been  generally  admitted  that,  while  all  caseation  (cheesy 
formation)  may  not  be  tuberculous,  true  tubercles  are  often  found 
in  scrofulous  lymphatic  glands.  Bazin,  Koster,  Friedliinder, 
JSTelaton,  Koux,  Lannelongue,  and  Brissaud  have  observed  them 
in  scrofulous  diseases  of  the  joints  and  long  bones  ;  Schtippel, 
in  those  of  the  skin;  Wagner,  Rindfleisch,  and  others  assert  their 
presence  in  nearly  all  cases  of  caseous  pneumonia.  Charcot  de- 
clares that,  in  all  instances  of  the  latter  affection,  the  caseous 
deposit  is  a  truly  tuberculous  mass.  Friedlander  insists  that 
tubercles  are  also  found  in  old  non-scrofulous  ulcers,  as  of  the 
cervix   uteri,  in  syphilitic  sores,  etc.     Virchow  considers   that 

1  Schonlein,  Virchow,  Jenner,  and  C.  West  are  among  those  who  have  denied  thia. 

c 


34 


GENERAL    PATHOLOGY. 


local  tuberculosis  may  occur  irrespective  of  any  general  diathesis, 
although  the  scrofulous  constitution  undoubtedly  predisposes  to  it. 
In  order  to  do  justice  to  the  views  of  those  pathologists  who 
regard  tuberculosis  and  scrofulosis  as  not  identical,  the  following 
comparative  table  is  subjoined,  from  Aitken.^ 


TUBERCULOSIS. 

Nervous  system  highly  developed ; 
mind  and  body  active;  figure  slim; 
adipose  tissue  small  in  quantity;  or- 
ganization generally  delicate;  skin 
tliin ;  complexion  clear,  superficial 
veins  distinct;  blush  ready;  eyes 
bright;  pupils  large;  eyelashes  long ; 
hair  silken ;  face  oval  and  good-look- 
ing ;  ends  of  long  bones  small ;  shafts 
thin  and  rigid;  limbs  straight;  the 
child  cuts  teeth,  runs  alone,  and  talks, 
early. 

Tendencies. — To  fatty  degeneration 
of  liver  and  kidneys;  growtli  of  tuber- 
cle, and  its  consequences;  inflamma- 
tion of  serous  membranes. 


SCROFULOSIS. 

Temperament  phlegmatic ;  mind 
and  body  lethargic ;  figure  heavy ; 
skin  thick  and  opaque;  complexion 
dull  and  pasty  looking ;  upper  lip  and 
alse  of  nose  thick ;  nostrils  expanded ; 
face  plain ;  lymphatic  glands  percep- 
tible to  the  touch;  abdomen  full; 
ends  of  long  bones  rather  large; 
shafts  thick. 

Tendencies. — Inflammation  of  mu- 
cous membranes  of  a  peculiar  kind ; 
so-called  strumous  ophthalmia;  in- 
flammation of  tarsi ;  catarrhal  inflam- 
mation of  mucous  membrane  of  nose, 
pharynx,  bronchi,  stomach,  and  in- 
testines; inflammation  and  suppura- 
tion of  lymphatic  glands  on  slight 
irritation;  obstinate  diseases  of  the 
skin ;  caries  of  bones. 

2.  Of  the  causes  apparently  connected  with  the  production  of 
the  tubercular  or  scrofulous  diathesis,  the  most  obvious  and 
frequent  is  hereditary  predisposition.  As  Sir  W.  Jenner  says% 
"  That  tuberculosis  is  transmitted  from  parent  to  child,  is  one  of 
the  best  established  facts  in  medicine." 

3.  This  diathesis  may,  however,  undoubtedly  be  acquired  with- 
out inheritance.  Change  of  climate,  from  a  warm  to  a  cold  and 
damp  locality,  will  often  induce  it.  Other  depressing  influences 
promote  it,  such  as  want  of  food,  light.,  pure  air,  and  warmth, 
dampness  of  situation  (Buchanan,  Bowditch),  sedentary  habits, 
etc.  But  all  of  these  often  fail  to  generate  any  form  of  tuber- 
cular disease.  Dr.  Wilks,  of  Guy's  Hospital,  London,  reasserts 
the  opinion  of  Barlow,  that  "tubercle  is  apt  to  be  developed  in 
an  organ  according  to  its  functional  and  vascular  activity  ;"  sup- 
porting this  by  Eokitansky's  observation,  that  cyanotic  patients, 
having  a  preponderance  of  venous  blood,  are  especially  free  from 
tubercular  disease  of  the  lungs.  But  Baudelocque,  McCormac, 
Parkes,  and  others  have  adduced  abundant  proof  that  close  living, 
in  an  impure  air,  is  highly  promotive  of  phthisis.  Probably  the 
normally  active  function  and  vascularity  of  the  lungs  render  them 
particularly  susceptible  to  injury  when,  in  an  impure  atmosphere, 
this  functional  activity  is  impeded  and  depressed. 

4.  Tuberculosis  may  be  pathologically  defined  as  a  constitu- 
tional tendency  to  the  formation  of  blood,  the  plasma  of  which 
is  defective  in  organizable  capacity  ;  so  that,  in  nutrition,  instead 
of  healthy  tissue,  it  forms  in  one,  or  very  often  in  many,  of  the 


1  Reynolds'  System  of  Medicine,  Article  Rickets. 

2  Tlie  Practical  Medicine  of  To-Day,  pp.  47,  48, 


CACHEXIA.  35 

organs,  aborted  blastema,^  which  caccumulates  as  a  deposit.  This 
deposit  is  called  tubercle  ;  the  process,  tuberculization.  This 
view  of  tubercle  has  been  denied  of  late,  it  appears  to  me,  upon 
insufficient  grounds.  Some  even  assert  a  specific  character  in 
tubercle.  Villemin,  Colin,  Lebert,  and  others,  declare  that  they 
have  propagated  it  in  animals  by  inoculation.  It  would  appear 
probable,  however,  from  the  Eejjort  of  a  Commission  of  the  French 
Academy  of  Medicine  upon  Villemin's  experiments,  that  '•'■all 
inflammatOT}!  products  have,  when  inoculated,  similar  effects  to 
those  of  tubercle."  Dr.  Marcet  of  London  confirmed,  by  experi- 
ments upon  animals,  the  inoculability  of  tubercle  from  the  sputa 
of  patients.  Max  Schottelius'^  produced  tuberculosis  in  animals 
by  compelling  them  to  breathe  air  saturated  with  bronchitic 
sputa,  powdered  cheese,  brain,  etc.  The  investigations  of  Metz- 
qner,  Friinkel,  Sanderson,  and  Wilson  Fox,  may  be  considered 
to  have  overthrown  Yillemin's  hypothesis  of  spewj^c  tubercular 
inoculation.^  Niemeyer  believed  that  while  a  peculiar  caseous 
metamorphosis,  most  frequently  the  result  of  inflammation,  may, 
by  resorption  and  infection,  propagate  phthisis  in  animals  inoc- 
ulated, yet  "a  purely  contagious  origin  of  actual  tuberculosis 
has  not  been  proven." 

Among  the  most  notable  observations  bearing  upon  this  ques- 
tion are  those  of  Drs.  H.  C.  Wood  and  H.  F.  Formad  (Suppl.  No. 
7,  Nat.  Board  of  Health  Bulletin,  1880),  in  connection  with  the 
inoculation  of  rabbits  with  diphtheritic  exudation.  In  every 
fatal  case,  necropsy  showed  tuberculization,  often  intense,  in 
internal  organs  ;  making  it  appear  that  diphtheritic  inoculation, 
in  those  animals  at  least,  produces  not  the  specific  malady,  diph- 
theria, but  the  non-si3ecific  cachexia,  tuberculosis. 

Chauveau,  of  Lyons,  and  Orth,  of  Gottingen,  both  assert  that 
they  have  produced  tubercular  disease  in  animals  by  feeding  them 
upon  material  from  tuberculous  lungs  of  cows.  We  might  have 
expected  that  such  material  would  prove  very  unwholesome  food; 
but  what  specific  disease  has  ever  been  shown  to  be  directly  thus 
transmitted?  Even  the  virus  of  rattlesnakes'  venom  is  usually 
harmless  when  swallowed,  if  no  abrasion  occasions  its  absorption 
unchanged  into  the  blood. 

5.  But  the  scrofulous  diathesis  may  exist  without  tuberculization. 
Its  influence  is  then  shown,  especially,  in  modifying  inflammatory 
or  other  morbid  ^jrocesses ;  giving  them  a  lower,  sloioer,  and  more 
persistent  or  intractable  type.  Thus,  many  cases  of  what  is  called 
tubercular  meningitis  in  children  occur,  with  fatal  result,  in  which 
(Bouchut,  Hughes  Wilshire,  etc.)  no  tubercular  deposit  is  found; 
yet  the  disease  is  modified  by  the  diathesis.  Some  regard  phthisis 
as,  in  like  manner,  a  tubercular  pnewnonia ;  but  this  designation 
can  only  apply,  properly,  to  a  certain  proportion  of  cases. 

6.  Tubercle  is  distributed  either  in  regularly-formed  masses 

1  From  pXacrravM.  I  bud;  used  to  mean  tissue-forming  material. 

2  Limcet,  Nov.  23,  187S. 

3  See  Brit,  and  For.  Medico-Chirurg.  Review,  July,  1868,  p.  26.  Chauveau,  however,  is 
asserted  to  have  shown  that  when  tubercle  and  pus  were  injected  in  filtered  solutions, 
only  tubercle  produced  tubercle.  (See  Damaschino  on  the  Etiology  of  Tubercle,  Ar- 
ehivcs  Gen.  de  Med.,  Oct.,  1872.) 


36 


GENERAL    PATHOLOGY. 


Yellow  Tubercle. 


(miliary  tubercles,  etc.),  or  irregularly,  through  the  tissues  of 
organs.     The  most  amorphous  (shapeless)  and  homogeneous  ex- 
amples of  it  have  been  called 
^i^- 1-  infiltrated  tubercle.    The  size 

of  the  masses  of  tubercle  varies 
from  that  of  a  pin's  head  to 
that  of  a  hen's  egg. 

7.  The  two  varieties  of 
tubercle  heretofore  described 
are  the  semi  -  transparent, 
gray,  granular,  and  the  yel- 
low, opaque,  caseous  tuber- 
cle.^ 

8.  Neither  of  these  forms 
ever  undergoes  organization. 
They  are  never  rasCT6?ar.  They 
are  deposited  outside  of  the 
blood-vessels,  and  not  in  non- 
vascular tissues,  such  as  carti- 
lage, etc.  Dr.  Beale  inclines  to  the  opinion^  that  tubercle  corpus- 
cles, sometimes  at  least,  originate  in  the  nuclei  of  the  vascular  walls. 
Cornil  and  Bastian^  entertain  analogous  views.  Schroeder  van  der 
Kolk,  Eadclyffe  Hall  and  others  consider  pulmonary  tubercle  to 
result  from  a  degeneration  of  the  epitheliallining  of  the  pulmonary 
air-cells.  Dr.  C.  J.  B.  Williams  has  applied  the  term  phthinoplasm 
to  the  degraded  bioplastic  material  of  the  blood  whose  formation 
is  attended  by  the  wasting  and  other  characters  of  "  consump- 
tion." Yirchow  describes  infiltrated  tubercle  of  the  lung  as  the 
cheesy  metamorphosis  of  an  exudation. 

9.  The  gray  tubercle,  when  alone^  may  be  subject  to  cornifica- 
tion ;  i.  e.,  drying  into  a  horny  substance  as  hard  as  a  shot. 

Fig.  2. 


Fig.  3. 


oo 


When 


Gray  Tubercle. 


Tubercle  Corpuscles 


with  the  yellow  tubercle,  or  after  conversion  into  it  (Eokitansky),^ 
the  gray  may  undergo  softening. 


1  Several  pathologists  now  assert  that  only  the  miliary  semi-transparent  and  opaque 
granular  matters  are  really  tubercular.  Further  allusion  to  this  question  will  be  made 
presently. 

2  Microscope  in  Pract.  Medicine,  1867,  p.  305. 

3  Edin.  Med.  Journal,  1867,  p.  875. 

4  Laeimec  accepted  this  conversion,  which  Rokitansky  for  a  long  time  denied,  but 
afterward  considered  frequent.  Virchow  admits  it,  and  Herard  declares  it  to  be  uni- 
versal. 


T  U  B  E  R  C  J;  K  . 


37 


10.  Yellow  tuhercle  iisnally  softens ;  sometimes  itcretifies  ;  i.  e., 
becomes  chalk-like,  by  degeneration. 

11.  The  softening  of  tubercle  is  sometimes,  at  least,  spontaiieons; 
not  depending  upon  any  agency  of  surrounding  parts.  In  regu- 
larly formed  tubercles  it  commences  at  the  centre ;  in  the  irreg- 
ular, at  «?)//  part.  Tuherculom  softening  must  not  be  confounded 
with  siq)puration  of  inflamed  tissue  ;  although  they  are  often  min- 
gled, and  have  been  considered  identical  by  some  pathologists, 

12.  Examined  with  the  microscope,  tubercle  is  found  to  consist 
essentially  of:  1.  An  amorphous^  granular  material,  containing 
irregular  solid  corpuscles  (tubercle-corpusclesl,  considered  (Vir- 
chow)  to  be  shrivelled  nuclei.  2.  Elements  of  disintegrated  tissue  of 
the  part  involved  ;  as  epithelial  cells,  fibres,  etc.  3.  Results  of 
degeneration;  e.  g.  oil-globules,  pigment,  calcareous  particles,  etc. 
4.  Results  of  inflanmiation  of  surrounding  parts  ;  lymph,  pus, 
exudation-corpuscles.  5.  Extravasated  blood-corpuscles,  from 
hemorrhage,  the  effect  of  obstruction  or  ulceration  of  vascular 
trunks.  With  these,  giant  cells  are  observed.  Rokitansky,  Vir- 
chow, Wagner,  and  others  have  recognized  these,  under  diflerent 
names.  Prof.  Schuppel  (of  Tubingen)  gives  the  following  account 
of  the  constituent  elements  of  a  tubercle  :  1.  Multinuclear  giant- 
cells,  resembling  the  "  myeloplaxes  "  of  myeloid  or  giant-celled 
sarcoma  ;  2.  Large  cells  of  an  epithelial  type  ;  3.  Small  round  cells 
like  lymph-corpuscles ;  4.  A  peculiar  reticulum,  in  the  meshes  of 
which  these  cells  he.  This  pa- 
thologist considers  the  giant-  Fig.  4. 
cells  to  be  the  essential  element 
of  tubercle  ;  although  the  bulk 
of  it  consists  of  cells  of  an 
epithelial  type.  As  observed 
in  the  lymphatic  glands,  he  as- 
serts that,  after  a  short  stage 
of  "development,"  each  tu- 
bercle undergoes  retrogressive 
changes.  These  are  :  1.  Ne- 
crosis, leading  to  caseation  and 
its  sequelae  or  terminations, 
cretification,  and  softening  ;  2. 
Transformation  into ^&roMS  tu- 
bercle; 3.  Eormation  of  calca- 
reous or  other  concretions  in 
the  centre  of  the  tubercle  ;  4. 
Resorption,  which  is  probably  Multinucleated  Cell  "(with  nucleoli)  from 
always  preceded  by  necrosis  of  luug  in  chronic  phthisis  (Green). 
the  tubercle. 

13.  Tubercle  contains  no  truly  specific,  heterologous  form.  All 
that  it  holds  is  the  consequence  of  abortion  and  degeneration. 
The  contrary  has  been  asserted  (1880)  by  Cohnheim  and  others, 
who  speak  of  a  tubercular  "virus."  I  consider  this  to  be  neither 
proved  nor  probable.^ 

1  Among  the  observations  claimed  to  support  the  "ino.  ulability "  of  tubercle,  are 
those  of  ToussaiQt  (Journal  de  Med.  et  de  Chirurgie,  May,  18S0)  upon  swine;  producing 
"galloping  cousumptiou  "  in  them  by  feeding  or  inoculating  them  with  tuberculous 

4 


38 


GENERAL    PATHOLOGY. 


14.  The  process  of  tuberculization  or  deposit  of  tubercle  in  an 
organ  may  occur  (Rokitansky) — 

a.  Insensibly,  in  the  course  of  ordinary  nutrition. 
h.  With  hyperaemia,  or  local  determination  of  blood, 
c.  With  inflammation ;  i.  e.,  as  a  product  or  concomitant  of  the 
inflammatory  process. 

15.  The  effects  of  the  tubercular  deposit  wpon  the  part  are :  1. 
Obstruction,  and  arrest  or  impairment  of  function.  2.  Inflam- 
mation ;  e.  g.,  in  phthisis  pulmonalis  (consumption),  which  has,  in 
its  usual  form,  been  sometimes  designated  (Condie)  tuhercular 
pneumonia^  from  the  common  occurrence  of  inflammation  of  the 
lungs  with  deposit  of  tubercle.  3.  Ulcerative  destruction  of 
thetissue  by  the  repeated  new  formation  and  softening  of  tuber- 
culous matter,  producing  cavities. 

16.  Tubercle,  once  thrown  out,  is  never  (as  a  whole)  absorbed. 
It  can  only  be  eliminated,  cretified,  or  cornifled.  Elimination  is 
the  most  common.  After  this  has  happened,  sometimes  callous 
cavities  are  formed  by  a  process  of  cicatrization. 

17.  The  order  of  frequencij  with  which  different  organs  are  af- 
fected with  tubercle  is  (Rokitansky)  as  follows  : 

Lungs ;  Spleen  ; 

Intestines ;  Kidneys  ; 

Lymph-glands  ;  Liver ; 

Larynx ;  Bones ; 

Serous-membranes  ;  Uterus ; 

Brain ;  Testicles. 

Except  in  the  case  of  children.,  in  whom  the  lymph-glands  and 
the  spleen  stand  first  on  the  list. 

Willigk,  in  1317  cases  of  tuberculosis,  found  the  order  of  fre- 
quency as  follows  :  lungs,  intestines,  mesenteric  glands,  larynx,  lym- 
2)hatic  glands,  peritoneum.,  spleen,  kidneys,  pleura,  liver,  air-pjassages, 
bones,  genitalprgans,  brain,  cerebral  membranes,  urinary  passages,  etc. 

18.  But  the  organs  most 
Fig.  5.                                frequeniiy  first invadedhy 

tubercle  are,  at  all  times 
of  life,  the  lung's  and 
lymph-glands. 

19.  The  parts  especially 
preferred  by  tubercle  for 
its  deposit  are,  in  the 
lungs,  the  apex  ;  in  the 
pia  mater,  about  the  base 
of  the  brain;  in  the  brain, 
the  gray  substance  ;  in 
bones,  the  cancellated 
structure  ;  in  the  bowels, 

the   lowest   part   of  the 

Miliary  Tubercles.  ileum  ;  in  the  testicle,  the 

epididymis  ;  in  the  female 
generative  apparatus,  the  Fallopian  tubes  and  fundus  of  the  uterus. 

matter,  or  by  injecting  blood  from  tuberculous  animals.  Per  contra,  reference  may  be 
again  made  to  the  experiments  of  H.  C.  Wood  aud  Formad,  who  produced  tuberculiza- 
tion by  inoculation  with  diphllierUiu  matter. 


TUBERCLE.  39 

20.  The  immense,  experience  of  Tlokiliinsky  has  sustained  to 
the  statement  that  tubercle  has  certain  i2;eneral  incompatibili- 
ties; the  most  im])ortant  of  which  arc,  witli  cancer,  with  typlius, 
with  ague,  and  with  goitre  (bronchoccle,  (snlargement  of  the  thy- 
roid giand).  These  incompatibilities  are,  however,  general,  not 
universal;  as,  for  instance,  a  considerable  number  of  cases  have 
been  observed,  in  which  cajicer  and  tubercle  were  undeniably 
present  in  the  same  patient.  Burdel  (1HG9)  observed  this  in 
more  than  a  hundred  instances. 

21.  The  only  possible  cure  of  tubercular  disease  (e.  f/.,  of  the 
lungs  in  phthisis)  after  the  deposit  has  occurred,  consists  in  the 

Fig.  6. 


Apex  of  Tuberculous  Lung. 

total  eliminatioii  (or  absolute  quiescence  by  cornification  or  ere- 
tification)  of  the  tuberculous  matter,  and  wiprovement  in  the  gen- 
eral hsematosis  (i  e.,  blood  formation),  so  that  no  new  tubercle  is 
formed.  The  two  gi-eat  indications,  therefore,  in  the  treatment 
of  pulmonary  consumption  (Radclyffe  Hall)  are,  to  gain  time  and 
tone ;  time,  by  allaying  or  preventing  pulmonary  or  bronchial  in- 
flammation and  irritation  ;  and  tone,  by  strengthening  the  pa- 
tient's system  by  all  possible  hygienic  and  therapeutic  measures. 
The  following  additional  remarks  upon  tuberculosis  are  made 
necessary  by  discussions  in  connection  with  the  views  of  Virchow, 
Oppolzer,  and  Niemeyer,  and  others  on  the  pathology  of  phthisis. 
A  retrospect  of  the  history  of  the  subject  will  show  that  (after 
Bayle)  Laennec  ^  first  established  the  doctrine,  sustained  after- 

1  Dr.  Thomas  Percival  asserted,  in  1789,  that  "inflammation  is  only  an  occasional 
concomitant  of  the  formation  and  softening  of  tubercles."  This  has  been  admitted  by- 
Graves,  Trousseau,  Brichetcau,  and  Jaccoud.  See  Teissier,  London  Med.  Becord,  Feb. 
5,  1873. 

It  appears  to  have  been  Portal  who  first  definitely  applied  the  term  luherculous  to 
what  are  now  conunonly  called  caseous  deposits.  Sylvius,  ^luad,  Culleu,  Reid,  and 
especially  Baillie,  described  the  process  of  their  forraatior.  Bayle  anticipated  Laennec 
in  teaching  the  existence  of  a  tuberculous  diathesis;  he  made,  however,  six  kinds  of 
cunsumptioD,  of  which  one  was  "granular,"  and  another  "tubercular." 


40 


GENERAL    PATHOLOGY. 


wards  with  great  vigor  by  Louis,  that  tubercle  is  a  specific  pro- 
duct of  a  diathesis;  that  there  are  two  varieties  of  it,  the  miUary 
semi-transparent,  and  the  yellow  infiltrated  ;  and  that  tubercle  is, 
when  deposited,  causative  of  inflammation.  Andral  maintained 
about  the  same  opinion.  In  consistency  with  his  other  pathologi- 
cal views,  Broussais  insisted  that  the  yellow  infiltration  is  certainly 
inflammatory,  and  that  therefore  the  other  variety  must  be  so  also. 
Louis,  especially,  denied  this.  Andral,  Cruveilhier,  Reinhardt, 
Addison,  Condie,  and  others  have,  since  Broussais,  recognized  the 
importance  of  inflammation  as  b,  factor  in  the  history  of  pulmonary 
consumption.  Rokitansky  clearly  declared  the  belief,  that  both 
the  semi-transparent  granular  and  the  opaque  caseous  forms 
ought  to  be  considered  as  tiiberculous  exudates :  the  gray  imder- 
going  cornification  when  alone,  and  softening  when  present  with 
the  other  variety,  while  the  latter  may  either  soften  or  become 
cretified.  Yirchow,  Herard,  and  Cornil  assert  that  only  the 
miliary  transparent  and  opaque  granular  matters  are  really 
tubercles. 

Buhl  proposed  (1857)  the  theory  of  the  resorptive  origin  of 
phthisis ;  yellow  infiltration  occurring  first,  and  the  absorption 
of  a  portion  of  this  producing  the  semi-transparent  granular 
tubercles.  Waldenburg  and  others  have  supported  a  similar 
opinion.  The  idea  of  a  specific  tubercular  virus  is  associated 
with  this  view.  Niemeyer  accepted  the  assertion  of  the  depend- 
ence of  miliary  tubercle  upon  the  presence  of  caseous  masses ; 
but  without  so  positively  stating  the  nature  of  the  connection. 
The  order  of  occurrence  as  described  by  him  is — 1.  Catarrhal 
pneumonia  or  broncho-pneumonia  ;  2.  Caseous  pulmonary  infil- 
tration ;  3.  Secondary  formation  of  tubercle.  The  first  two 
of  these  stages  may  take  place,  in  many  cases,  even  of  fatal 
consumption,  without  the  third.  aSfiemeyer's  dictum  has 
become  quite  famous,  that  "the  greatest  danger  for  the  ma- 
jority of  consumptives  is,  that  they  are  apt  to  become  tuber- 
culous." 

On  the  other  hand,  the  well-known  experiments  of  Waldenburg, 
Frankel,  Burdon  Sanderson,  and  Wilson  Yox  lend  support  to  the 

view  that  the  miliary 
granulation  may  be  pri- 
mary, perhaps  infiani- 
matory,  and  the  yellow 
infiltration  the  result  of 
degeneration  either  of  tu- 
bercle, or  of  any  inflam- 
1  aatory  or  other  morbid 
product.  Dr.  C.  Ellis, 
if  Boston,  U.  S.,  pro- 
pounded this  as  the 
node  of  origination  of 
yellow  tubercle,  in  1860. 
V  irchow,  moreover,  has 
Cicatrix  of  Lung,  shown     that    "caseous 

masses"     occur     some- 
times entirely  without  the  previous  occurrence  of  pneumonia. 


Fig. 


TUBERCLE.  41 

With  Profs.  Austin  Flint  and  Alonzo  Clfirk,'  the  writer  is  not 
prepared  to  accept,  as  a  whole,  tlie  resorptive  theory  of  consump- 
tion, or  in  any  sense  the  necessarily  secondary  nature  of  tubercular 
deposits.  Dr.  AustinFlint's  careful  analysis  of  070  cases  of  phthisis 
(iV.  Y.  Medical  Record,  Feb.  1,  187)5)  alfords  substantial  clinical 
proof  that  neither  inflamnKdory  affections  within  the  chest,  nor 
hcvinojAysis,  can  have  nuich,  if  any,  causative  influence  in  the 
development  of  phthisis.  Nor  does  the  same  experience  present 
evidence  that  scrofulous  disease  of  the  glands  has  to  do  with  the 
etiology  of  pulmonary  tuberculosis.  The  following  questions  may 
be  regarded  as,  at  pi-escnt,  sub  Judice: 

1.  Are  both  the  semi-transparent  miliary  granulations  and  the 
yellow  caseous  infiltrations  to  be  called  tubercules,  or  only  one 
of  these  two  forms  ;  and,  if  but  one,  ivhich  is  tubercle  ?  This 
appears  to  be  a  question,  not  of  fixct,  but  of  nomenclature;  to  be 
decided  by  the  general  suftrage  of  the  profession.  Meantime, 
accuracy  in  clinical  description  requires  that  terms  be  used  which 
defnc  the  special  lesions  occurring  in  connection  with  phthisis, 
otherwise  than  by  the  use  of  the  words  tubercle  or  tuberculiza- 
tion alone.  On  the  whole,  it  seems  best  to  restrict  the  term 
tubercle  (in  accordance  with  etymology)  to  that  which  began,  at 
least,  as  a  nodule  or  nockiles ;  while  the  terms  caseous  deposit 
and  caseous  infiltration  may  well  apply  to  amorphous  (steatoma- 
tous  '?)  accumulations,  in  the  lungs  or  elsewhere.  Some  pathol- 
ogists (as  Bastian)  would  drop  the  term  tubercle  altogether. 
Granidar  degeneration  (Empis)  is  an  expression  used,  almost  in 
the  same  sense  by  a  few  authors.  But  nothing  seems  as  yet  to 
be  finally  settled  upon  this  point. 

2.  Does  one  of  the  above-mentioned  deposits  always  precede 
and  produce  the  other  ?  And,  if  so,  which  is  primary  ?  There 
is,  as  already  said,  much  in  favor  of  the  belief  that  caseous 
deposits  are  often,  if  not  mostly,  secondary. 

3.  Does  inflammation,  as  a  rule,  precede  and  produce  tubercle, 
or  tubercle  inflammation  ?  Likewise,  does  htemoptysis  produce 
tuberculization,  or,  as  Laennec  taught,  tuberculization  hsemop- 
tysis  ?  Against  the  general  causative  action  of  pulmonary  hem- 
orrhage, we  have  the  valuable  experiments  of  Perl  and  Lipmann'^ 
and  Sommerbrodt,  showing  that  blood  passing  into  the  sound  lung 
does  not  of  itself  act  as  an  irritant,  but  is  gradually  absorbed  with- 
out prodiicing  any  observable  change,  unless  moderate  em- 
physema. 

Some  facts  in  the  clinical  history  of  pulmonary  and  other  affec- 
tions in  children  militate  against  the  "catarrhal  broncho-pneu- 
monia" and  "resorptive"  theories  of  consumption.  Thus,  1. 
Scrofulous  caseous  formations  or  degenerations  of  glands,  mucous 
membranes,  and  bones  are  common  in  children,  without  tubercle 
of  vital  organs  following  in  many  cases.  Yirchow  has  assented 
to  the  importance  of  this.  2.  Catarrh,  bronchitis,  and  even  bron- 
cho-pneumonia, are  more  common  in  children  than  in  adults  ;  and 

1  N.  Y.  Medical  Record,  Nov.  15, 1870.    Mandl  also  rejects  the  "caseous-pneumonia" 
theory  of  phthisis ;  Traube  and  Skoda  deny  at  least  "  plithisis  ab  haemoptoe." 
»  Virchow's  Arehiv.,  Band  xlix.,  Heft  2. 

4* 


42  GENERAL    PATHOLOGY. 

yet  pulmonary  phthisis  is  much  more  rare  during  childhood  than 
later  in  life. 

Litten,  of  Berlin,  in  some  elaborate  investigations  of  acute 
tuberculosis/  has  sustained  the  statement  that  "tubercles  may 
develop  extensively  in  the  membranes  of  the  brain,  without  a 
trace  of  exudation."  This  must  be  admitted,  I  believe,  by  most 
pathological  anatomists. 

Considerable  attention  has  been  given  lately  to  the  giant  cells 
found  in  tubercular  deposits.  Schrceder  von  Kolk  described 
these  many  years  ago  as  "  compound  cells,  consisting  of  epithe- 
lium charged  with  the  nuclei  which  become  the  ordinary  tubercle- 
corpuscles."  Yirchow^  referred  to  them  as  "larger  cells  with  a 
manifold  division  of  the  nuclei,  so  that  twelve,  twenty-four,  or 
thirty  are  contained  in  one  cell."  They  are  irregular  in  form, 
without  any  cell-wall,  the  largest  about  ^^^  of  an  inch  in  diam- 
eter. Each  contains  from  three  or  four  up  to  thirty  or  forty 
nuclei,  which  are  conspicuously  nucleolated.  Branching  pro- 
cesses extend  from  many  of  them,  making  a  reticulated  arrange- 
ment, occupied  with  epithelioid  elements.  This  adenoid  (gland- 
like) net-work  is  regarded  by  Rindfleisch  as  characteristic  of 
tubercle.  Small  round  cells  also  infiltrate  (in  the  lungs)  the  alve- 
olar walls  of  the  air  vesicles.  The  giant  cells  do  not  appear  ever 
to  undergo  further  development. 

What  is  their  nature  ?  It  is  not  clear  that  they  are  entitled  to 
the  name  of  cells  at  all.  Klein  and  Da  Costa^  believe  them  to  be 
excessively  developed  or  fused  epithelial  cells.  Cornil  holds  that 
they  result  from  the  coagulation  of  plasma  in  capillaries  in  course 
of  obliteration.*  Malassez^  believes  rather  that  they  are  vaso-form- 
ative  cells,  which  abort  without  development.  Kiener  and  Poulet^ 
assert  the  occurrence  of  a  fusiform  enlargement  of  a  blood-vessel, 
or  more  rarely  a  lymphatic  vessel,  and  an  agglomeration  of  cells 
around  this  enlargement ;  the  endothelial  cells  of  the  capillary 
walls  also  undergoing  a  "vitreous  degeneration,  and  becoming 
fused  together  into  a  solid  cylinder,  a  transverse  section  of  which 
presents  the  appearance  of  a  giant  cell."  Woodward^  agrees 
with  Yirchow  in  interpreting  the  change  as  occurring,  not  in  ca- 
pillaries but  in  lymphatic  vessels.  "Around  the  vessel,"  he  says, 
"  at  the  point  of  obstruction,  lymphoid  cells  accumulate  in  a 
group.  These  are  probably  a  swarm  of  migrated  white  cor- 
puscles, while  the  large  endothelial  elements  are  produced  by 
the  gradual  enlargement  of  the  fixed  corpuscles  of  the  area  of 
connective  tissue  involved."  The  tendency  of  all  the  above 
interpretations  is  to  sustain  a  view  favoring  the  essentially  abor- 
tive and  degenerative  nature  of  tubercle,  rather  than  that  of 
its  being  an  organized  neoplasm,  as  held  by  Wedl,  Vogel,  and  Yir- 

1  Volkmann's  Sammlung  Klinischer  Vortrage,  No.  119, 1878. 

2  Cellular  Pathology,  Lecture  xx. 

3  Philada.  Medical  Times,  June  19,  1880,  p.  469. 

*  Cornil  draws  a  distinction  between  tlie  scrofulous  and  the  tuberculous  process,  even 
when  both  occur  in  the  lymphatic  glands  ;  the  reticulated  tissue  belonging  especially 
to  the  scrofulous  formation.     (Allg.  Med.  Cont.  Zeit.,  Sept.  20,  1879.) 

6  London  Med.  Record,  June  15,  1878. 

6  Gazette  Medicale  de  Paris,  I'eb.  28,  1880. 

7  Second  Medical  Volume  of  Medical  and  Surgical  History  of  the  War,  1879 ;  p.  593, 
et  seq. 


TUBERCLE. 


43 


Fig.  8. 


chow,  or  a  specific  wfection  or  contagion^  as  lately  urged  by 
Cohnheim,  Harnsell,'  and  others. 

Amongst  other  prominent  pathologists,  Charcot  (1878)  distinctly 
avowed  the  conviction  that  "caseous  pneumonia  or  pneumonic 
phthisis  is  a  tuberculous 
disease."  Da  Costa'^  has 
expressed  a  similar  opin-' 
ion. 

CorniF  asserts  the  dis- 
covery of  a  pigmentary  ac- 
cimiulation  in  the  giant 
cells  of  some  tuberculous 
formations,  by  which  so- 
lidity is  given  to  the 
deposit,  and  thus  the 
patient's  life  may  be  pro- 
longed. 

On  the  whole,  without 
venturing  to  dogmatize  on 
so  difficult  a  subject,  the 
following  seems  to  be  the 
most  probable  conclusion : 
That  there  is  a  certain 
constitution,  often  but  not 
always  inherited,*  having 
a  proclivity  to  the  precip- 
itation^ under  reduction  of 
vital  force,  of  semi-organ- 
ized granular  and  corpus- 
cular deposits  from  the 
blood  ;  ^  in  the  glands, 
mucous  membranes,  and 
bones  in  childhood,  con- 
stituting scrofula ;  in  the 
membranes  of  the  brain, 
at  the  same  period,  mak- 
ing tubercular  meningitis ; 
later  in  life,  usually  in  the 
lungs,  producing  phthisis ; 
that  such  deposition  may  occur  without  inflammation  as  a  cause, 
and  may  then  produce  inflammatory  disturbance ;  while  it  is, 
not  rarely,  thrown  down  under  the  influence  of  local  inflamma- 
tion, especially  when  pus  is  formed  ;  also,  that  resorption  is  not 
the  usual,  but  may  possibly  be  an  occasional  mode  of  origination 
of  tuberculization,  in  the  lungs  or  elsewhere;  and  that  by 
breathing,  swallowing^  or  inoculation  of  tuberculous  or  other 

1  Graefe's  Archiv.,  2o,  part  iv.,  1879. 

2  Philada.  Medical  Times,  June  19,  1880,  p.  472. 

3  Le  Progr6s  Medical,  1880,  p.  866. 

*  "  It  cannot  be  assumed,"  says  Vircliow,  "  that  caseous  pneumonia  creates  no  inher- 
itable tendency." 

^  Dr.  W.  Minor  Logan,  of  Cincinnati,  asserts  the  importance  oiphosphatic  deposits  in 
tuberculosis;  owing  especially  to  deficiency  of  oxidation. 

0  Toussaint,  Journal  de  Med.  et  de  Cbirurg.,  May,  1880;  Bollinger,  Archiv,  fur  Exp. 
Pharm.  and  Pathol.,  Vol.  I.,  Nos.4  and  5, 1873. 


Section  through  a  Lymphatic  in  aTubeicu- 
lous  Bowel.  X  480.  a,  granular  fibiin-clot; 
b,  b,  loosened  endothelial  elements.  (From 
the  Second  Medical  Volume  of  the  Med. 
and  Surg.  History  of  the  War.  Photo- 
micrograph by  Surgeon  J.  J.  Woodward, 
U.S.A.) 


44  GENEEAL    PATHOLOGY. 

degenerated  animal  matter,  the  tendency  to  the  production  of 
tubercular  deposits  may  sometimes  be  promoted.  I  persist,  how- 
ever, in  denying  the  existence  of  a  specific  virus  in  tubercle,  such 
as  has  been  recently  compared  by  Cohnheim  to  that  of  syphilis. 

If  these  views  be  correct,  it  must  be  recognized  as  a  fact  that 
fatal  pulmonary  phthisis  may  occur  under  several  forms :  1.  Most 
commonly,  as  a  progressively  degenerative  affection  of  the  lungs, 
with  intercurrent,  usually  successive  attacks  of  inflammation, 
which  hasten  very  much  the  fatal  termination.  2.  As  a  tuber- 
cular or  "caseous"  pneumonia;  subacute  in  character,  or  even 
chronic;  but,  sometimes,  so  rapid  as  to  be  named  "acute  phthi- 
sis," or  galloping  consumption,  3.  As  a  simple,  slowly  progress- 
ing, cachectic,  non-inflammatory,  degenerative  disease ;  consti- 
tutional depravation  and  pulmonary  disorganization  going  on 
together,  and  death  occurring  sometimes  from  general  vital 
decline,  and  sometimes  from  pulmonary  obstruction  or  disability. 

(On  Depression  and  Exhaustion^  see  Sect,  iii.,  General  Thera- 
peutics. ) 

GENERAL  PATHOLOGY  OF  AFFECTIONS  OF  ORGANS. 

HYPERTROPHY. 

Hypertrophy  is,  strictly,  overgrowth ;  an  increase  of  the  size 
and  weight  of  a  part  without  change  of  tissue.  It  is  only  in 
recent  times  that  this  has  been  clearly  distinguished  from  enlarge- 
ment with  alteration  of  tissue;  which  is  really,  in  many  cases,  a 
degenerative  change,  and  therefore  akin  rather  to  atrophy  than  to 
hypertrophy. 

Hypertrophy  is  often,  per  se,  physiological  or  natural ;  although 
depending  on  a  morbid  or  pathological  cause.  "When  the  blad- 
der, for  instance,  becomes  hypertrophied  in  consequence  of  ob- 
struction by  an  enlarged  prostate,  although  the  latter  is  morbid, 
the  increase  in  the  strength  and  thickness  of  the  muscular  coat 
of  the  bladder  is  as  normal  as  is  that  of  the  uterus  during  gesta- 
tion ;  in  due  proportion  to  the  necessities  of  its  use. 

A  constant  law  of  the  animal  economy  is,  that,  within  certain 
limits,  the  growth  of  an  organ  is  in  proportion  to  its  exercise ; 
provided  that  this  exercise  is  not  too  violent,  and  is  alternated 
with  sufficient  periods  of  repose. 

The  three  causes  of  hypertrophy,  then,  are  (see  PageVs  Sur- 
gical Pathology)  : — 

1.  Increased  exercise  of  a  part  in  its  healthy  functions. 

2.  Increased  accumulation  in  the  blood  of  the  particular  mate- 
rials which  a  part  appropriates  in  its  nutrition  or  secretion. 

3.  Increased  afflux  of  healthy  blood  to  the  part. 

We  ixiay  illustrate  the  first  of  these  modes  of  causation  by  the 
blacksmith's  arm,  the  legs  of  the  danseiise,  the  cuticle  of  the 
laborer''s  hand,  the  heart  in  cases  of  valvidar  obstruction,  etc. 

An  example  illustrative  of  the  second  is  found  in  the  enlarge- 
ment of  a  healthy  kidney,  when  the  opposite  one  fails,  from 
disease,  to  remove  from  the  blood  its  due  share  of  urea,  etc. 

The  third  is  exemplified  in  the  large  growth  of  hairs  around 
an  inflamed  ulcer  or  osseous  fracture  ;  by  the  growth  of  the 


A  T  11  ()  P  II  Y 


HyijerCropiiy  of  Heart. 


bones  of  the  limbs  when  their  nutrition  is  increased  by  exercise; 
by  hj-^pertropliy  of  a  bone,  a  portion  of  which  has  l)een  subject 
to  disease  with  vascular  excitement;  and  by  Hunter's  interesting 
experiment  of  the  transplanta- 
tion of  the  spur  of  a  cock  to  Fig.  9. 
its  comb. 

Adaptative  hypertrophy  is 
remarkably  seen  in  tlie  changes 
undergone  l)y  the  skull  in  pro- 
portion to  its  contents.  The 
cranium  is  subject  to — 1,  eccen- 
tric, and  2,  concentric  hyper- 
trophy. The  first  occurs  in 
cases  of  Ivjdrocephahis^  the  sec- 
ond in  cerebral  atrophy;  the 
bony  case  in  the  one  instance 
expandimj  with  its  contents,  in 
the  other  thickening  so  as  to 
fill  up  the  abnormal  void. 

Corns  illustrate  hypertrophy 
extremely  well. 

Intennittent  pressure^  or  at- 
trition, causes  hypertrophy ; 
constant  pressure,  atrophy  or 
absorption. 

The  formation  of  corns  upon 
the  foot  illustrates  the  former 
of  these  laws  ;  the  wasting  away  of  vertebrae  under  the  incessant 
pressure  of  an  aortic  aneurism  affords  an  example  of  the  latter. 
A  Chinese  woman''s  bandaged  foot,  with  corns,  exemplifies  both.    ■ 

ATROPHY. 

Atrophy  requires  but  a  few  words  in  this  place.  Simple  atro- 
phy is  exactly  the  reverse  of  simple  hypertrophy  ;  viz.,  wasting 
and  diminution  of  a  part,  without  change  of  structure.  But 
most  pathologists  include  also  under  the  same  term  such  defects 
of  nutrition  as  result  in  degenerative  changes  ;  constituting  the 
two  classes  of^l,  quantitative,  and  2,  qualitative  atrophy.  "The 
latter  (e.  gr.,  fatty  degeneration)  is  frequently  attended  by  increase 
instead  of  diminution  of  bidk  in  the  parts  aflected. 

The  causes  of  atrophy  are  :^ 

1.  Deficient  exercise  of  a  part ; 

2.  Deficiency  in  the  supply  of  blood ; 

3.  Defective  supply  of  nervous  influence; 

4.  Disease  (inflammation,  etc.)  in  the  part. 

Of  the  first  of  these,  the  atrophy  of  the  mamma  of  the  old 
maid  may  aflbrd  an  example. 

Of  the  second,  softening  of  a  portion  of  the  brain  from  the 
obstruction  of  one  of  its  arteries  by  a  coagulum. 

Of  the  third  and  first  together,  the  muscles  of  a  paralyzed  limb. 

Of  the  last,  there  are  many  instances  familiar  to  the  pathol- 
ogist, although  obscurity  often  attends  their  individual  history  ; 
as  the  gouty  kidney,  etc. 


46  GENERAL    PATHOLOGY. 

Quantitative  or  qualitative  atrophy  may  affect  the  heart,  arte- 
ries, brain,  muscles,  bones,  liver,  kidneys,  pancreas,  testicles,  etc., 
and  also  morbid  products,  e.  g. ,  inflammatory  exudations,  cancer, 
etc. 

Qualitative  atrophy,  or  degeneration,  will  be  again  alluded  to 
presently. 

lEBITATION. 

Irritation  and  inflammation  are  at  once  the  most  familiar  in 
their  phenomena,  and  the  most  obscure  in  their  nature,  of  all 
pathological  processes  or  occurrences.  I  shall  confine  myself  to 
a  broad  statement  of  what  I  believe  to  be  most  important  truths 
concerning  them  ;  although  a  somewhat  argumentative  tone  may 
be  unavoidable,  upon  topics  which  are  subject  to  so  much  con- 
troversy. 

Stimulatioii  and  irritation  are  often  inconveniently  confounded. 
It  would  be  desirable  to  confine  the  former  term  to  excitation 
within  physiological  limits ;  applying  the  latter,  irritation,  only  to 
such  an  excessive  action  upon  a  part  as  produces  ^morbid  effects. 

With  this,  which  seems  to  me  a  necessary  postulate  —  I  would 
define  irritation  as  an  arrest  of  vital  movement  in  a  part.  This 
could  only  be  elucidated  by  an  extended  allusion,  inappropriate 
here,  to  the  correlation  of  physical  and  vital  forces  ;  life  being  con- 
sidered as  a  molecidar  motion. 

In  regard  to  the  circulation,  to  the  old  and  accepted  maxim — 

Ubi  stimulus,  ibi  affluxus — 

may  be  added  a  second — 

Ubi  irritatio,  ibi  stasis — 

and,  anticipating  the  account  about  to  be  given  of  inflammation, 
a  third — 

Ubi  phlogosis,  ibi  effusio. 

The  stasis  of  irritation  may  be  either  partial  or  complete ;  lim- 
ited to  a  very  small  surface,  or  widely  extended ;  and  transient,  or 
continued  for  a  considerable  time. 

If  comptlete,  extended,  and  continued  in  a  tissue  at  all  vascular, 
inflammation  follows. 

If  the  influence  of  the  irritant  be  very  limited  and  transient,  a 
temporary  stasis,  with  functional  and  sensational  disturbance 
only,  follows. 

If  it  be  extended  and  continued,  or  repeated,  and  yet  of  power 
enough  to  produce  a  partial  stasis  only,  a  condition  may  result  to 
which  the  name  of  chronic  inflammation  has  been  commonly 
given  ;  of  which  more  will  be  said  hereafter. 

The  effects,  or  symptoms,  of  irritation  difier  according  to  the 
tissue  or  organ  affected.  When  a  nervous  expansion  or  centre  is 
involved,  pain  is  the  most  familiar  result.^  Functional  disorder, 
of  the  part  innervated,  also  occurs.  Irritation  of  muscular  tissue 
causes  tonic  spasm. 

'  Inman  and  Radclifife,  especially,  have  insisted  that  pain  is  always  a  sign  of  local 
diminution  of  vital  energy;  it  is  on  the  way  toward  death. 


INFLAMMATION.  47 

INFLAMMATION. 

Inflammation  must  be  considered  briefly,  as  to  its  sympfoms, 
minute  phenomena,  ^noducts,  terminations  or  effects,  and  post-mortem 
api)earances. 

Its  recognized  symptoms  or  signs,  in  a  part  open  to  inspection, 
are  redness,  heat,  swelling,  and  pain. 

In  internal  organs  inflammation  is  detected  chiefly  by  pain, 
increased  by  pressure  or  motion ;  obstruction  or  alteration  of  the  func- 
tional action  of  the  organ ;  and  general  (sympathetic)  vascular 
excitement.  Certain  physical  signs  also  aid  in  the  diagnosis  of 
inflammation  of  particular  organs  (see  Semeiology). 

The  minute  phenomena  of  inflammation,  as  seen  under  the 
microscope,  have  been  variously  construed  by  different  observers. 
The  use  of  the  term  itself  has  been,  of  late  years,  distorted  (Yir- 
chow)  from  its  old  meaning  ;  and  attempts  have  been  made  by 
some  (Andral,  Eiscnmann,  Bennett)  to  do  away  with  it  entirely  ; 
attempts  which  fail,  because,  in  proposing  other  terms,  apart 
only  is  substituted  for  the  whole.  It  is  curious,  that,  of  the  three 
terms  proposed  b}''  three  leading  pathological  writers,  hyper- 
aemia,  stasis,  and  exudation,  to  take  the  place  of  the  old  word 
inflammation,  each  expresses  a  single  part  or  element  of  the  pro- 
cess, which  can  only  be  defined  by  including  them  all;  while  cell- 
distension  and  cell-multiplication,  made  by  Virchow  so  prominent 
in  the  process,  are  only  incidental  attendants  upon  it. 

The    essential   minute    phenomena   of  inflammation   are,    as 
regards  the  circulation  — 
Central  stasis  ; 
Concentric  hypersemia ; 
Exudation. 

Other  changes  aflfecting  the  red  and  white  corpuscles,  etc., 
occur,  but  are  of  secondary  consequence. 

The  nature  and  cause  of  these  phenomena  require,  for  their  com- 
prehension, a  close  consideration  of  the  laws  which  govern  nutri- 
tion, the  capillary  and  arterial  circulation,  and  innervation,  in 
their  mutual  relations,  under  the  influence  of  normal  stimuli  and 
of  morbid  irritants. 

What  are  the  actual  causes  of  inflammation  ? 

Not  section  of  the  nerves ;  nor  division  of  the  arteries  {per  se); 
nor  divisions  of  the  veins  ;  nor  ligation  of  arteries  nor  of  veins  ; 
nor  {per  se)  of  lymphatics.  Only  such  causes  as  modify  the  molec- 
ular state  of  the  tissue,  and  arrest,  for  the  time,  the  usual  inter- 
change of  material  between  the  tissue  and  the  blood,  can  induce 
a  true  inflammation. 

Let  us,  then,  revert  to  our  maxims.  Ubi  stimulus,  ibi  affluxus. 
Stimulation  causes  active  hyperccmia.  The  arteries  thus  exhibit 
reflex  action  ;  a  fact  which,  in  spite  of  the  teachings  of  Unzer, 
Hunter,  and  C.  Bell,  has  been  denied  or  misunderstood  by  nearly 
every  other  physiologist  and  pathologist  down  to  the  present 
day.' 

1  Much  of  the  accepted  pathology  of  to-day,  and  some  current  notions  in  therapeu- 
tics, arc  founded  upon  an  orroneous  view  of  the  physiolotry  of  the  circulation,  espe- 
cially in  regard  to  the  mode  of  action  of  the  arteries.     Tlie  error  is,  the  statement 


48  GENERAL    PATHOLOGY. 

Next,  uhi  irritatio,  ibi  stasis.  Stimulation,  carried  to  morbid 
excess,  interrupts,  by  the  molecular  disturbance  it  induces,  the 
normal  life-movement  of  the  part,  and  checks  the  interchange  of 
particles  going  on  between  the  capillaries  and  the  tissue.  Thus 
the  circulation  in  the  capillaries  of  the  part  is  arrested ;  stagnation 
ensues. 

Both  of  these  results,  active  arterial  hypersemia  and  capillary 
stasis,  follow  from  the  same  or  sim.ilar  causes  acting  in  different 
degrees.  They  may  and  do  exist  together;  the  one  (capillary 
stasis)  at  the  very  point  of  irritation,  the  other  (active  hyper- 
semia) in  the  vessels  surrounding'  it. 

What  follows  ?  Hydraulics  may  answer  this  question,  A 
quantity  of  fluid  in  (minutely  or  potentially)  porous  vessels,  being 
forced  upon  a  centre  whose  condition  allows  little  or  none  of  it 
to  be  transmitted,  an  effusion  must  result,  through  the  more  or 
less  distended  coats  of  the  vessels. 

This  is  expressed  by  our  third  maxim :  TJbi  phlogosis  (inflam- 
mation), ibi  effusio.  This  phenomenon,  the  "exudation,"  has 
attracted  almost  all  the  attention  of  many  pathologists,  to  the 
exclusion  of  other  occurrences  which  precede  and  accompany  it, 
—  an  exclusion  which  has  had  detrimental  results  (J.  Hughes 
Bennett)  as  regards  the  practical  and  therapeutical  deductions 
made  therefrom.  The  importance  of  the  part  taken  by  the  arte- 
rial circulation  in  inflammation  is  well  illustrated  by  the  control 
exercised  over  it  in  acute  cases,  as  recorded  by  a  number  of 
observers,  by  the  ligation  or  compression  of  the  main  artery  of  the 
limb  or  other  part  aflected.^ 

Virchow  has  another  theory  of  inflammation,  forming  a  part 
of  his  "Cellular  Pathology."  He  identifies  (confounds)  stimu- 
lation, which  is  physiological  or  normal,  with  irritation,  always 
abnormal  or  pathological  in  kind  or  degree.  All  irritation,  in 
vascular  or  non-vascular  parts,  is,  according  to  him,  either  func- 
tional, nutritive,  ov  formative.  Exudation,  or  transudation  of  fluid 
into  the  substance  of  an  inflamed  part,  is  admitted  only  of  the 
more  vascular,  soft,  and  superficial  tissues.  In  others  (paren- 
chymatous inflammation)  the  essential  efiect  of  irritation  of  a 
high  degree  is  said  to  be,  the  taking,  by  their  own  action  or  at- 
traction, of  more  fluid  into  the  cells  of  the  organ  or  tissue.  Thus 
they  swell  and  become  clouded  in  aspect  under  the  microscope. 
Next  the  nucleus  divides ;  and  afterwards  the  cells  themselves 
multiply  by  division,  or  proliferate.  The  origination  of  pus  or 
other  cells  from  entirely  liquid   lymph,  as  asserted  by  Paget, 


(based  upon  experiments  whose  results  were  only  morbid,  not  normal)  that  the  normal, 
active  contraction  of  the  arteries  always  diminishes  the  supply  of  blood  through  them ;  as 
Virchow  expresses  it  "  ^Ae  Tnore  active  the  vessel,  the  less  the  supply  of  blood."  Another  gen- 
eration will  attain  to  the  correction  of  this ;  and,  with  it,  a  revolution  in  the  pathology 
of  inilammation  must  occur.  See  the  author's  Prize  Essay  on  the  Arterial  Circulation, 
Trans.  Amer.  Med.  Association,  1856.  More  recently  (1858)  lAster  asserted  reflex  action 
as  occurring  in  the  vessels  in  inflammation ;  as  well  as  the  central  arrest  of  nutrition. 
A  brief  suinmary  of  the  arjjument  is  given  by  the  author  in  Am.  Journal  of  Med.  Sci- 
ences, July,  1868,  p.  288 ;  and  again,  in  the  Trans,  of  the  Amer.  Med.  Association,  1872, 
p.  181.  An  admission  of  the  true  view,  based  on  the  experiments  of  Legros  and  Onimus, 
occurs  in  the  Brit,  and  Foreign  Medico-Chirurg.  Review,  April,  1871,  pp.  291, 303. 

1  See  an  article  on  this  subject  by  S.  W.  Gross,  M.D.,  Philadelphia  Medical  Times, 
Januarv  16th,  1871. 


INFLAMMATION.  49 

Kobin,  and  others,^  Yirchow  denies,  in  accordance  with  his 
maxim  "omnis  cellula  e  ctsllula."  Either  the  epithelial  cells  or 
those  of  the  connective  tissue  (common  germ-stock  of  all  tissues) 
must  give  rise,  by  change,  to  pus-cells.  At  a  certain  stage  cell- 
enlargement  and  proliferation  become  destructive  of  function ; 
the  parts  then  degenerate.  But  Virchow  does  not  with  any  dis- 
tinctness at  all  state  the  relation  between  this  degeneration  and 
that  nutritive  ov  formative  action  which  he  considers  the  one  eft'ect 
of  "irritation;"  nor  does  he  allow  to  the  condition  of  the  blood- 
vessels enough  importance  in  what,  in  any  tissue,  he  calls  inflam- 
mation. 

This  eminent  pathologist  has  added  to  previous  knowledge  that 
of  the  changes  going  on  in  the  cells  of  an  organ,  a  part  of  which 
is  inflamed.  These  are  important.  But  he  omits,  in  his  account 
of  the  process,  much ;  and  makes,  on  the  whole,  the  least  satis- 
factory theory  of  it  lately  held  by  any  authority. 

To  return  to  our  account  of  it :  an  example  of  the  three  stages 
or  processes  of  stimulation,  irritation,  and  inflammation  may  be 
well  studied  in  the  action  of  a  mustard  plaster  applied  to  the  skin. 
Its  first  effect  (the  only  one  if  the  mustard  be  diluted)  is  stimulant 
merely ;  the  skin  grows  warmer  and  redder,  and  its  sensibility  is 
moderately  heightened.  Next  (if  it  be  strong  and  allowed  to 
remain),  irritation  is  produced ;  shown  by  ixdn,  tenderness  on 
pressure,  and  a  deeper  or  more  purple  redness.  If  the  irritating 
matter  be  now  withdrawn,  all  of  these  may  subside  without  going 
further.  But  if  the  irritation  be  continued  up  to  a  certain  point 
of  duration  and  intensity,  inflammation  occurs.  Then  we  have 
redness,  heat,  pain,  and  swelling,  with  effusion  of  lynjph,  which, 
as  after  a  cantharidal  plaster,  raises  the  cuticle  in  a  blister. 

I  express,  then,  what  I  hold  to  be  a  correct  theory  of  the  nature 
of  the  inflammatory  process,  in  this  definition :  Inflammation  is  a 
local  lesion  of  nutrition,  with  concentric  vascular  excitement;  result- 
ing in  either  exudation  or  cell-distension  and  proliferation;  being 
destructive  at  the  centre  of  the  inflamed  part,  but  often  formative 
[hi I  per  plastic)  around  and  at  some  distance  from  it. 

The  observations  of  Cohnheim,  of  Berlin,  have,  since  1867, 
attracted  great  attention.  He  announced  (after  Addison,  1841, 
and  Waller,^  1846),  that,  in  an  inflamed  part,  some  of  the  color- 
less corpuscles  of  the  blood  (leucocytes)  migrate  through  the 
walls  of  the  capillaries,  and  become  blood-corpuscles.  Without 
waiting  even  for  the  complete  establishment  by  others  of  this  as 
a  fiict,  some  rushed  at  once  to  the  assumption  of  a  new  theory 
of  inflammation,  making  it  to  consist  entirehj  in  this  cell-emigra- 
tion !  Rashness  in  pathological  speculation  could  hardly  go 
further  than  this.  As  Strieker^  has  shown,  however,  Cohnheim's 
labors  have  recalled  attention  to  the  changes  in  the  circulation 
during  inflammation ;  while  other  sources  of  pus-cells  must  be 
admitted.     It  may  be  added  that,  in  view  of  the  known  fact  that 

1  Herard  and  Cornil  (on  Pulmonary  Phthisis,  1867),  after  minute  and  prolonged  in- 
vestigation, declare  that  ''the  theory  of  proliferation  cannot  altogether  take  the  place 
of  that  of  new  formation  at  the  expense  of  pre-existing  hlastema."  Paget  appears  to 
be  inclined,  recently,  to  give  it  up. 

2  Philosoph.  Magazine,  vol.  xxix.,  pp.  271.  39S. 

*  Studien  aus  dem  Inst,  fiir  experiment.  Pathol.,  Wien,  1869. 

5  D 


50  GENERAL    PATHOLOGY. 

pressure  increases  osmose,  this  escape  of  corpuscles  through  the 
walls  of  the  capillaries  must  find  its  best  explanation,  partly  at 
least,  in  the  increased  jyressure  already  alluded  to  in  our  descrip- 
tion of  inflammation.^ 

The  products  of  inflammation  (by  exudation)  are  (see  PageVs 
Surgical  Pathology) :  1.  Serum.    2.  Blood.    3.  Mucus.    4.  Lymph. 

The  inflammatory  effusion  of  non-fibrinous  serum  is  rare.  The 
term  is  often  applied,  however,  clinically,  to  a  serosity  which  con- 
tains a  small  proportion  of  fibrin,  as  the  effusion  which  follows 
pleurisy,  etc. 

Blood  is  exuded  occasionally  only ;  e.g.,  in  dysentery,  in  ne- 
phritis, and  (dissolved)  in  pneumonia. 

Mucus,  a  certain  portion  of  which  constantly  moistens  the  sur- 
face of  mucous  niembranes  in  health,  is  altered  both  in  character 
and  in  amount  by  inflammation.  The  general  statement  is,  that 
when  a  mucous  membrane  is  inflamed  (e.g.,  in  bronchitis)  its 
secretion  of  mucus  is  at  first  arrested,  then  increased,  and  lastly 
perverted  in  character. 

Coagulahle  lymph  is,  however,  the  characteristic  ingredient  of 
inflammatory  exudations. 

Inflammatory  lymph  is  divided  by  Paget  into  —  1,  fibrinous, 
and  2,  corpuscular  lymph  ;  with  the  assertion  that,  as  a  general 
fact,  the  more  fibrin  a  specimen  of  lymph  contains  (provided  it 
be  healthy  fibrin),  the  greater  the  probability  of  its  being  organ- 
ized into  tissue  ;  while  the  larger  its  proportion  of  corpuscles,  the 
greater  is  the  likelihood  of  suppuration  or  some  other  degenera- 
tive process,  and  the  more  tardy  its  development  into  any  kind 
of  tissue.  (Note  an  at  least  apparent  exception  to  this  in  the  case 
of  diphtheritic  exudation.) 

Fibrinous  (coagulable  or  plastic)  lymph  is  very  well  seen  in  the 
autopsy  of  any  case  of  acute  pleurisy,  peritonitis,  meningitis,  etc. 

It  is  a  whitish  or  yellowish-gray  substance,  opaque  or  semi- 
translucent  after  coagulation,  arranged  in  fibrous  bands,  meshes, 
or  layers,  and  causing  adhesions  between  contiguous  portions  of 
the  tissues  affected. 

Corpuscular  lymph  may  be  studied  in  the  fluid  of  the  vesicles 
of  herpes,  or  of  an  ordinary  blister,  especially  if  the  surface  of 
the  latter  have  been  exposed  to  the  air  for  a  short  time. 

The  lymph-  or  exudation-corpuscles  which  it  is  found  (under 
the  microscoi)ej  to  contain,  are  about  osso  of  an  inch  in  diameter, 
"round  or  oval,  pellucid,  and  appearing,  as  if  through  irregu- 
larities of  surface,  dimly  nebulous  or  wrinkled."  Examined 
after  a  few  hours  under  the  action  of  water,  a  round  and  pellucid 
nucleus  is  observed  within  and  attached  to  the  cell-wall.  It  is, 
however,  impossible,  in  a  given  instance,  to  make  a  positive 
microscopical  diagnosis  between  these  corpuscles  of  inflammatory 
lymph  and  the  normal  lymph  or  chyle  corpuscles,  colorless  cor- 
puscles of  the  blood,  and  pus  corpuscles. 

The  "biography"  of  the  lymph  of  exudation  consists  in  its 
resorption  or  its  development  into  connective,  fibrous,  elastic, 

J  Strieker  thus  states  the  results  o>)scrved  in  experimental  inflammation :  "  traumatic 
interference,  disturbance  of  circulation,  exudation  of  fluid  and  morphological  constit- 
uents, disturbances  of  nutrition,  now  formation." 


INFLAMMATION.  51 

osseovis,  cnrtilafjinous,  or  vascular  tissue,  or  into  epithelium,  etc. 
(rarely  into  muscular  or  nervous  tissue),  or  its  degeneration  into 
pus,  or  (jranule  cella^  exudation  (/ranulcs,  etc. 

The  rapid  resorption  of  a  moderate  amount  of  exuded  lymph 
constitutes  the  resolution  of  an  intlammation. 

Its  development  is  also  a  form  of  resolution,  but  with  modifi- 
cation of  the  condition,  dimensions,  etc.,  of  the  i:>art.  This  is, 
in  some  instances,  merely  restorative. 

The  degeneration  of  the  exudation  results  in  its  being  throvm 
off,  as  pus,  or  finalh/  absorbed ,  in  the  form  of  molecular  exudation- 
granules. 

Whether  immediate  absorption,  development,  or  suppurative 
or  granular  degeneration  shall  occur  in  any  particular  case  of 
inflammation  will  depend — 

1.  On  the  state  of  the  blood ; 

2.  On  the  seat  of  the  inflammation ; 

3.  On  the  degree  of  inflammation. 

(See  Paget's'  experiments  as  to  the  influence  of  the  state  of  the 
blood  on  the  lymph  of  vesication. ) 

As  to  the  seat  of  the  attack,  genercdly,  serous  and  synovial  tis- 
sues (pleural,  peritoneal,  arachnoid,  articular)  are  most  subject 
to  (ulhesive  inflammation,  i.e.,  with  the  exudation  of  fibrinous 
lymph.  Mucous  tissues  seldom  exhibit  this,  being  more  prone  to 
su2)purative  inflammation.  (Exceptions  in  croup,  dipMlieria,  etc.) 
Parcnchi/matoua  tissues,  as  those  of  the  lungs,  liver,  etc.,  when 
inflamed,  may  suppurate,  or  the  lymph  exuded  may  degenerate 
into  exudation  granules,  and  be  finally  absorbed. 

The  degree  of  the  inflammation  exercises  an  important  influ- 
ence. The  greater  its  intensit}^  or  severity  (i.e.,  the  more  de- 
cided and  extended  the  local  lesion  of  nutrition  and  the  concentric 
hypercnnia),  the  further  will  the  lymph  exuded  be  removed,  in 
its  primary  chax-acter,  from  that  transuded  iu  the  natural  state 
of  the  part,  and  the  more  will  its  subsequent  changes  differ  from 
those  of  normal  nutrition  and  development. 

Degeneration  may  affect  both  the  fibrinous  and  the  corpuscular 
portions  of  inflammatory  lymph. 

The  fibrinous  part  is  subject  to — 

1.  Drying  into  horny  concretions  (as  on  the  valves  of  the  heart, 
from  endocarditis). 

2.  Feitty  softening. 

3.  Liquefactive  degeneration. 

Both  of  these  last  contribute,  no  doubt,  to  the  process  of  sup- 
puration. Calcareous  and  pigmental  degeneration  are  also  de- 
scribed as  occurring  in  it  occasionally,  but  they  are  less  important. 

The  corpuscular  portion  of  lymph  may  also  undergo — 

1.  Withering  and  drying  (as  in  scrofulous  inflammation  of 
glands). 

2.  Conversion  into  gramde  cells  (inflammatory  globules  of 
Gluge),  hy  fatty  degeneration. 

3.  Calcareous,  or 

1  Surgical  Pathology,  Phil,  ed.,  p.  220. 


52 


GENERAL    PATHOLOGY. 


4.  Pigmental  degeneration. 

5.  Host  commonly,  degeneration  of  the  lymph-cells  into  pus- 
cells  ;  the  whole  of  the  lymph  being  transformed  into  pus. 

Pus  is  a  greenish-yellow,  creamy  fluid,  consisting,  under  the 
microscope,  of  the  liquor  puris  and  pus-cells  or  corpuscles.  Tlio 
latter  are  definite  cell  forms,  larger  than  blood  or  lymph  cor- 
puscles, somewhat  more  irregular,  and  often  containing  several 
nuclei.  Their  characters,  however,  are  not  invariably  distinctive; 
as  might  be  anticipated,  from  their  being  merely  transformed  or 

degenerated  lymph,  blood,  of 
Fig.  10.  epithelial  corpuscles  ;  or,  in 

a  wound  or  ulcer,  cells  of 
granulation.  The  assertion 
of  Cohnheim,!  ^f  33erlin,  that 
pus-corpuscles  are  white 
blood-cells  which  have  em- 
igrated through  the  un- 
broken walls  of  the  blood- 
vessels, should  not  be  finally 
accepted  without  very  full 
confirmation.  Professor 
Koster,  of  Utrecht,  thinks 
he  has  obtained  similar  re- 
sults. Professor  K.  Balogh,^ 
of  Pesth,  after  great  care, 
failed  to  confirm  them ;  and 
the  same  is  reported  by 
Feltz  and  Picot.  Lebert,  Strieker,  Caton,  Woodward,  and  others 
find  their  observations  to  accord  with  them.  If  the  fact  of  migra- 
tion (Recklinghausen)  of  the  colorless  corpuscles  be  granted,  it 
does  not  follow,  as  Strieker  has  shown,^  that  all  pus-cells  are  of 
this  origin.  Some,  most  probably,  are,  as  before  taught  by  Paget 
and  Virchow,  of  local  origin.  Strieker  announces  his  discovery 
of  the  divisio7i  of  the  "nomadic  cells  or  pus-corpuscles."  It  has, 
perhaps,  also,  not  yet  been  proved  to  be  quite  impossible,  that 
what  Cohnheim  believes  to  be  emigrating  corpuscles,  may  be 
nuclei  of  the  capillary  walls,  which,  as  described  by  Beale* 
"are  at  definite  intervals,  often  on  alternate  sides  of  the  tube," 
and,  according  to  his  opinion,  "  may  give  origin  to  the  white 
corpuscles." 

Chemically,  pus  may  be  approximatively  tested  by  its  solubility 
in  liquor  potassce. 

Suppuration  is  either  circumscribed  (as  in  abscess),  diffusive 

(in  erysipelas),  or  superficial  (in  leucorrhoea,  etc.). 

The  effects  of  inflammation  upon  the  part  or  organ  involved  are 

Enlargement ;  Degeneration  ; 

Induration  i ;  Ulceration  ; 

Softening ;  Mortification. 


A.  Pus  Corpuscles  (magnified  350  diame- 
ters). B.  Same  made  transparent  with 
acetic  acid.  a.  Cell  wall.  b.  Nucleus, 
c.  Nucleolus.    (After  Lebert.) 


1  Virchow,  Archiv.  Band  40,  s.  38. 

2  Brown-Sequard's  Archives  de  Physiol.,  etc.,  1869. 

3  Studien  aus  dem  Instit.  fur  experiment.    Pathol.,  1869.    See,  also,  a  paper  by  Dr. 
S.  H.  Chapman  ;  Am.  Journal  of  Medical  Sciences,  October,  1872. 

4  Microscope  in  Practical  Medicine,  1867,  pp.  165, 166. 


INFLAMMATION, 


53 


We  thus  see  that  very  different  or  even  opposite  results  may- 
follow  from  different  deqrces  or  kinds  of  inflammatory  action. 

Specific  inrtammatiohs  require  merely  to  be  mentioned  here. 
They  are,  chiefly,  scrofulous,  erysipelatous,  rheumatic,  gouty, 
diphtheritic,  exanthematous,  syphilitic,  gonorrhoeal.  These  are 
distinguished  from  ordinary  inflammation  and  from  each  other 
in  that— 1,  each  exhil)its  a  peculiar  pMn  of  morbid  process ;  2, 
each  depends  upon  a  peculiar  cause;  3,  the  effects  of  the  said 
cause  are  irrespective  of  its  quantity  mostly  \  4,  they  are  especially 
diffusible  from  one  part  of  the  body  to  another ;  5,  they  sometimes 
exhibit  definite  stages  of  the  morbid  process  (e.  g.  primary  and 
secondary  syphilis);  G,  they  are  nearly  all,  in  a  more  strict  sense 
than  other  inflammations,  self -limited  \  the  morbid  process  dying 
out  after  a  certain  time.  (This  last  statement  applies  especially, 
if  not  only,  to  exanthematous,  diphtheritic,  rheumatic,  gouty,  and 
gonorrhoeal  inflammations  ;  hardly  to  the  scrofulous,  erysipelatous, 
and  syphilitic.)  It  maybe  questionable  whether  erysipelatous 
inflammation  is  a  truly  specific  process  •,  as  reason  has  been  shown 
for  believius;  that  its  peculiar  character  may  be  owing  to  the 
tissue  which  it  chiefly  affects ;  viz.,  that  of  the  lymphatic  system. 

Fig.  11. 


Bands  of  Lymph  in  Peritonitis. 

The  post-mortem  appearances  of  inflammation  are  important. 
They  can  be  generalized,  so  as  to  avoid,  to  a  great  extent,  the 
necessity  of  their  reiteration  in  connection  with  the  description 
of  particular  diseases.  It  is,  at  the  same  time,  necessary  for  the 
student  to  familiarize  himself  with  them,  in  their  local  manifes- 
tations, by  availing  himself  of  every  opportunity  for  autopsic 
study. 

A  part  which  has  been  inflamed  will  exhibit  after  death  some, 
or  perhaps  all,  of  the  following  signs  : 


54  aENEEAL    PATHOLOGY. 

Bedness ;  Coagulable  lymph ; 

Enlargement  of  Pus ; 

blood-vessels ;  "  Softening ; 

Tumefaction ;  Induration, 

The  redness  of  inflammation  must  be  distinguished  with  care 
from — 1st,  hypostatic  injection,  or  cadaveric  settling  of  blood  in  the 
lowest  parts,  by  gravitation ;  and  2d,  physiological  redness,  as  of 
the  stomach  during  digestion,  the  ovaries  during  menstruation, 
etc.  Inflammatory  redness  is  usually  more  unequal  than  either 
of  the  above,  and  is  stellated,  or  in  streaks  and  patches. 

Enlargement  of  the  blood-vessels  of  a  part  may  occur  as  the 
result  of  a  chronic  affection,  different  from  acute  inflammation. 
This  sign,  therefore,  is  to  be  interpreted  with  great  caution. 
The  same  is  true  of  tumefaction  (general  swelling  of  the  part). 

Softening,  if  not  cadaveric  (as  when  the  body  has  been  long 
defunct),  may  have  been  produced  by  chemical  action,  as  in 
poisoning  by  corrosive  sublimate,  etc.,  by  acute  and  rapid  inflam- 
m,ation,  or  by  slow,  non-inflammatory  degeneration. 

Induration  may  also  follow  either  acute  inflammation,  or  slow, 
atrophic  degeneration. 

Sclerosis  is  the  term  now  commonly  applied  to  it,  especially  in 
connection  with  morbid  affections  of  the  cerebro-spinal  system. 

The  presence  of  bands  or  membranes  of  coagulable  lymph  is 
indisputable  evidence  of  inflammation  having  occurred  in  the 
part.  But  it  is  not  easy,  in  all  cases,  to  determine  with  certainty 
whether  such  formations  are  old  or  new. 

The  existence  of  pus  is  a  still  stronger  sign  of  the  recent  exist- 
ence of  inflammation  ;  but,  occasionally,  instances  occur  in  which 
pus,  produced  by  inflammation  in  one  part,  is  conveyed  (as  in 
phlebitis)  by  the  veins,  etc.,  and  deposited  in  another.  This,  al- 
though a  rare  event,  is  possible  at  least. 

Clearly,  therefore,  no  one  of  the  above  post-mortem  signs  of 
inflammation  is  sufficient  alone.  Several  of  them  together  will  make 
the  diagnosis  certain.  Bedness  and  enlargement  of  hlood-vessels, 
with  lymph  or  pus,  and  softening  or  slight  induration  of  tissue, 
will  leave  little  or  no  doubt  in  any  case. 

The  variations  in  the  appearance  of  different  organs  and  por- 
tions of  the  body,  in  fatal  cases  of  inflammatory  disease,  are  not 
such  as  to  interfere  with  the  correctness  and  availability  of  this 
general  description. 

CHRONIC   INFLAMMATION. 

The  term  "chronic  inflammation,"  as  commonly  applied,  is  a 
misnomer.  Although  the  cases  so  designated  exhibit  more  or 
less  redness,  heat,  swelling,  and  pain,  yet  they  are  wanting  in 
exudation;  without  which,  pathologically,  there  is  no  inflamma- 
tion. There  is  also,  in  the  same  cases,  only  a  partial  stasis  or 
none;  and  the  hyperoimia  is  less  intense  and  less  strictly  concen- 
tric than  in  acute  inflammation. 

The  characteristics  of  this  state,  for  which  a  new  term  is 
wanted,  are — 

1.  Enlargement  of  the  blood-vessels  of  a  part  (chronic  hyper- 
semia),  with  the  flow  of  a  large  amount  of  blood  through  it. 


DEGENERATION.  56 

2.  Exaggeration  of  the  sensibility  of  the  part  (hypersesthesia) 
and  morbid  irritability. 

3.  Deficient  or  irregular  functional  power. 

4.  Unusual  proneness  to  acute  or  subacute  attacks  of  actual 
inflammation. 

For  this  familiar  combination  of  pathological  elements  I  pro- 
pose the  name  hyperaemaestliesia. 

It  has,  with  some,  boon  usual  to  designate  it  by  the  term 
"irritable,"  in  connection  with  the  name  of  the  particular  part 
aflected,  thus — 

Irritable  uterus  ; 

Spinal  irritation  ; 
to  which  I  would  add — 

Irritable  eye  (chronic  ophthalmia) ; 

Irritable  stomach  (chronic  gastritis) ; 

Irritable  brain,  etc. 

Erythromelalgia  is  a  descriptive  name  applied  to  an  unusual 
affection  of  the  extremities  (nearly  always  the  feet)  observed  and 
reported  upon  by  Graves,  Vulpian,  Weir  Mitchell,^  Launois,^  and 
others.  Its  signs  are,  burning  pain,  bright  red  flushing  of  the 
feet,  turgescence  of  the  blood-vessels,  and  violent  arterial  pulsa- 
tions, with  local  increase  of  temperature.  It  is  clearly  a  condi- 
tion of  active  hyperKinia,  with  hypercesthesia.  (According  to  the 
erroneous  current  ideas  of  vaso-motor  physiology,  it  is  called  by 
authors  an  instance  of  vaso-motor  paralysis;  which  I  hold  to  be 
precisely  opposite  to  the  truth.  Consistently  with  such  a  view, 
symmetrical  gangrene  is  said''  to  result  from  "  peripheral  vascular 
spasm  ;"  a  veritable  reductio  ad  absurdum.) 

DEGElSTERATTOlSr. 

Degeneration  has  been  already  defined  as  qualitative  atrophy ; 

i.  e.,  a  substitution,  under  decline  of  the  organic  force  incessantly 
active  in  nutrition  and  repair,  of  abnormal  for  normal  structure 
and  material. 

The  forms  under  which  this  occurs  are— 

Fatty  degeneration ; 

Calcification ; 

Pigmental  degeneration ; 

Fibroid,  colloid,  and  amyloid  degeneration  ; 

Liquefactive  and  corpuscular  degeneration. 

Amyloid  degeneration  has  been  described  by  Yirchow  and  others 
as  occurring  in  the  brain,  spleen,  liver,  etc.  It  consists  in  the 
conversion  of  tissue  into  a  substance  which  is  made  reddish-brown 
by  iodine,  instead  of  yellow,  as  the  healthy  tissues  would  be.  It 
is  also  characteristically  stained  of  a  violet  color  by  methyl-aniline 
(methyl  green). 

Hyaline  degeneration  of  the  vessels  and  substance  of  the  lym- 

1  Am.  Journal  of  Med.  Sciences,  July,  1878.     , 

2  Paralfsie  Vaso-Motrice  des  ExtreinitJs,  ou  Erythromelalgie.    Paris,  1880. 
8  Am.  Journal  of  Med.  Sciences,  April,  1881,  p.  539. 


66 


GENERAL    PATHOLOGY. 


Fig 


phatic  glands  has  been  described  by  Wieger  (1880).  A  translu- 
cent substance  is  formed,  very  slightly  colored  by  iodine,  but 
deeply  stained  by  carmine. 

In  regard  to  these  alterations  it  may  be  stated  (see  PageVs 
Surgical  Pathology)  that 

1.  They  are  changes  such  as  may  be  observed  naturally  occur- 
ring, in  one  or  more  parts  of  the  body,  at  the  approacn  of  the 
natural  termination  of  life. 

2.  The  new  material  is  of  lower  chemical  composition  than 
that  normal  to  the  part ;  i.  e.,  it  is  less  removed  from  the  inor- 
ganic state  :  as  fat,  gelatin,  calcareous  matter,  etc. 

3.  In  structure,  it  is  less  developed ;  being  crystalline,  granu- 
lar, simply  globular,  etc. 

4.  In  function,  it  is  less  powerful. 

5.  In  nutrition,  it  is  less  active  and  capacious. 

6.  Generally^  although  not  ahoays,  constitutional  debilitation 
precedes,  and  (we  may  infer)  institutes  the  local  alteration  of 
structure. 

7.  Inflammation  or  other  local  disease  niay,  by  impairing  the 
nutrition  of  a  part,  cause  it  to  degenerate. 

The  form  of  degenerative  disease  which  has  received  the  most 
attention  from  pathologists  is  fatty  degen- 
eration. This  has  been  carefully  studied,  as 
it  occurs  in  the  heart,  arteries  (atheroma), 
brain,  muscles,  bones,  liver,  kidneys,  and 
morbid  products.  It  must  be  distinguished 
carefully  from  mere  fatty  accumulation  or 
adiposity. 

Our  knowledge  of  the  facts  concerning  de- 
generative disease,  and  of  the  share  which 
it  claims  in  the  domain  of  structural  pathol- 
ogy, once  almost  entirely  usurped  by  in- 
flammation, is  among  the  most  important 
of  the  acquisitions  of  the  medical  science  of 
the  last  half  century. 

MORBID  GROWTHS. 

Tumors,  and  morbid  growths  benign  and 
malignant,  which  may  be  best  classified  as 
forms  of  structural  degeneration  or  vitiated 
nutrition,  I  leave,  at  present,  except  to  state 
the  following  classification  (Cornil  and  Ran- 
vier,  Bristowe): — 
Connective-tissue  tumors ;  viz., 

Fibroma,  of  fibrous  tissue. 

Lipoma,  of  fatty  material. 

Myxoma,  of  mucous  tissue. 

Cartilaginous  tumors,  Chondromata. 

Osseous  tumors,  Osteomata. 

Nervous  tumors,  Neuromata. 

Muscular  tumors,  Myomata. 

Vascular  tumors,  Angiomata. 


Fatty  Infiltration  of  MuS' 
cle  (magnified). 


AtORRID   GROWTHS. 


57 


Glandular  tumors,  Adenomata.^ 

Embryonic  tissue  tumors,  Sarcomata. 

Syphilitic  tumors,  Gtimmata. 

Alveolated  epithelial  tumors,  (Jardnomata. 

Cancer  or  cfmi»o»iaf;illsitndcr  the  notice  and  care  of  the  medi- 
cal practitioner,  when  it  attacks  parts  or  organs  within  any  of  the 
great  cavities  of  the  body. 

There  is  no  essential  impropriety  in  classing,  pathologically, 
all  malignant  growths'  together  as  cancerous ;  their  subdivisions 
being  clinical  or  surgical.     (By  malignant,   we  mean  prone  to 

Fig.  13. 


Cells  of  Cancer  of  Tongue. 

unlimited  increase :  disastrous  in  effect  or  result ;  and  difficult  or 
impossible  of  arrest  or  cure.) 
Cancers  may,  then,  be  divided  simply  into 

Scirrhus,  or  hard  cancer  (fibro-carcinoma) ; 
Colloid,  or  gelatiniform  (alveolar)  cancer ; 
Encephaloid,  or  brain-like  (medullary)  cancer.^ 
Each  of  these  contains,  as  its  anatomical  elements,  fibres,  fluid, 
or  semi-fluid  jelly,  and  cells. 

Scirrhus  is  composed  mainly  of  a  fibrous  or  filamentous  tissue, 
with  little  fluid,  and  comparatively  few  cells.  It  never  becomes 
encephaloid,  nor  does  encephaloid  cancer  ever  become  scirrhus. 

1  Lymphomala. 

-  Tubercle  is  not  a  growth,  but  rather  an  abortion  of  tissue. 

8  Other  names  are  used,  as  epitheUal,  melanoid,  osteoid,  hcrmaloid,  myeloid,  and  villous 
cancer,  enchondroma,  round-celled,  spindle-celled  and  giant-celled  sarcoma,  etc. 


68 


GENERAL    PATHOLOGY. 


Colloid  cancer  has  a  variable  amount  of  fibrous  tissue,  arrayed 
as  a  matrix  (compared  often  to  the  structure  of  an  orange),  con- 


FlG.  14. 


Fig.  15. 


Colloid,  exterior. 


Interior  of  Colloid. 


taining  a  jelly-like  substance ;  cells  also  may  be  found  in  it,  but 
in  less  proportion. 
Encephaloid  cancer  is  (so  to  speak)  the  highest  development  of 

Fig.  16. 


Myeloid  Sarcoma.     (Virchow.) 

carcinomatous  formation.  It  consists  of  a  fibrous  matrix,  con- 
taining an  abundance  of  abnormal,  multiform  cells,  and  a  pecu- 
liar fluid. 


MORBID    GROWTHS. 


69 


When  a  cancer,  of  either  type  originally,  is  based  upon  and  in- 
cludes bony  structure,  it  constitutes  osteosarcoma.  If  it  develop 
itself  upon  the  skin,  or  other  epithelial  tissue,  or,  wherever  occur- 
ring, display  similar  structure,  it  may  be  called  epithelioma.  If  its 
location  involve  especial  vancularitij  and  hemorrhage,  it  assumes 
the  form  and  name  of  fmvjus  lurmalodea.  The  pain  of  cancer 
(which  is  not  always  present)  appears  to  depend  upon  the  exten- 
sion of  the  disease  to  a  tissue  well  endowed  with  nerves. 

The  cells,  tibres,  and  tluid '  of  cancer  are  all  abnormal. 

Cancer-cells  are  of  various  shapes,  resembling  gland-cells,  but 
larger,  averaging  about  y^^jg-  of  an  inch  in  diameter. 

But  are  these  forms  heterologous;  i.  c,  different  from  anything 
normal  or  natural  to  the  body?  Are  they,  so  to  speak,  inipAanta- 
tions,  or  distortions?  I  believe,  fully,  that  the  latter  is  the  correct 
view.  The  "cancer-cells"  are  no  longer  held  by  micrologists  to 
be  pathognomonically  distinctive ;   they   are  homologous  with 


Colloid  Cancer.     (Rindfleisch.) 


other  cells  found  in  the  body.  Yet,  they  are  such  forms  ns  do  not 
normally  belong  to  the  part;  being  produced  by  morbid  alteration 
or  perversion  of  its  natural  elements;  especially  the  epithelial 
elements. 

They  are,  moreover,  crowded  together  abnormally,  in  the  meshes 
of  an  imperfectly  and  irregularly  distributed  connective  tissue ; 
and  with  a  great  number  of  nuclei^  often  large  in  proportion  to  the 
cells.  Classen's  opinion  (1870)  that  cancer  always  originates  in  a 
morbid  development  of  migrated  leucocytes  (white  blood-corpuscles) 
is  extremely  unlikely  to  be  correct.     The  view  of  Thiersch  (1865) 

I  The  milky  or  creamy  "cancer-juice,"  which  emulsifies  with  wator,  is  considered 
highly  characteristic  by  many  observers.  The  malignily,  or  proneness  to  Increase,  and 
extend  destructively,  of  a  tumor,  is  generally  in  proportion  to  its  succulence  or  juici- 
ness. The  lawless  mmmer  of  gj-owth  of  cancer-cells,  compared  with  the  regular  apposition 
of  those  of  the  same  part  when  healthy,  is  very  important. 


60  GENERAL    PATHOLOGY, 

and  Waldeyer  (1867),  ascribing  cancerous  growths  to  a  modifi- 
cation in  the  cell-multipUcation  of  ordinary  epithelium,  is  more 
probable.  This  view  is  favored  also  by  Rindfleisch ;  who,  how- 
ever, admits  as  one  mode  of  growth  of  epithelial  cells,  their  deri- 
vation from  wandering  formative  cells,  in  contact  with  existing 
epithelium.' 

The  most  rational  theory  of  cancer  is  dynamic.  The  disease 
consists  in  a  morbid  tendency ;  a  tendency  to  enormous  and  un- 
healthy growth  of  a  formation  which  is,  at  the  same  time,  vascular 
and  sensitive,  showing  subserviency,  although  under  perversion^ 
to  the  physiological  laws  of  the  organization. 

The  origin  of  cancer  in  most  cases,  is  constitutional ;  it  is  fre- 
quently hereditary.  A  cancerous  cachexia  is  recognized  in  very 
many  cases ;  its  most  obvious  sign  is  a  peculiar  sallowness  of  the 
skin.  It  follows  much  more  rapidly  upon  cancers  of  the  viscera 
than  upon  those  of  external  parts. 

Genuine  cancer  may  always  be  expected  to  return  after  removal 
— although  exceptions  occur,  and  it  has  occasionally  been  known 
to  undergo  spontaneous  degeneration. 

The  order  of  choice  which  cancer  exhibits,  as  to  the  parts  it 
attacks,  is  (Rokitansky)  as  follows : — 


Uterus ; 

Liver ; 

Testicle ; 

Mamma ; 

Bones ; 

Ovary ; 

Stomach ; 

Skin; 

Tongue ; 

Rectum ; 

Brain ; 

(Esophagus, 

Lymph-glands ; 

Eye; 

Colloid  cancer,  in  particular,  prefers  the 

Stomach,  rectum,  peritoneum. 
Scirrhus,  the 

Mamma,  stomach,  intestines. 
Micephaloid  may  occur  in  any  organ  ;  it  alone  attacks  the 

Liver,  kidney,  lung,  testicle,  eye,  lymph-glands. 

NBURO-PATHOLOGY. 

The  pathology  of  the  nervous  system  is,  itself,  an  extensive 
field,  of  which  the  merest  coup  d^ceil  is  possible  here. 

For  the  purposes  of  pathological  study,  we  must  remember  that 
the  anatomical  elements  of  the  nervous  apparatus  are — 1,  gray, 
vesicular  ;  and  2,  white,  tubular  ;  and  3,  gray,  gelatinous  nervous 
substance  ;  the  first  being  arranged  in  ganglia,  the  latter  two  in 
nerves  and  commissures. 

Physiologically,  the  functions  of  the  ganglia  (nerve-centres,  and, 
probably,  impressible  peripheral  ganglionic  expansions  also)  are,  to 
receive,  reflect,  accumulate  (generate?)  and  distribute  nerve-force. 
The  sole  function  of  nerves  and  commisswes  is,  to  transmit  or  con- 
duct it. 

As  a  whole,  we  may  state  the  otfices  of  the  nervous  apparatus 
to  be  as  follows  : — 


lit  is  a  proposition  not  yet  proven,  that  "  wandering  leiicocytes"  take  part  in  tlie 
formation  of  any  tissue  whatever.    I  believe  it  to  be  extremely  doubtful. 


NEURO-PATHOLOGY.  61 

Excito-mntor  ;  Internuncial,  i.  c, 

Excito-sccrctory  ;  Sympathetic  and 

Sensory;  Synergic  (co-ordinative); 

Voluntary  motor;  Psychical,  i.  e.,  mental. 

The  forms  of  disorder  to  which  this  apparatus  is  liable,  are 

1.  Anaesthesia;  i.  c,  that  condition  in  which  the  patient  re- 
mains without  cognizance  of  impressions  made  on  a  surface  which 
is  normally  sentient.  This  may  result,  a,  from  disease  of  the  ner- 
vous expansion  at  the  surface;  h,  from  disease  or  injury  of  the 
conducting  nerve,  somewhere  on  its  track  ;  c,  from  disease  of  the 
cerebral  sub-centre  of  sensation  (sensorium).  The  thalami  are 
believed  by  physiologists  gencu-ally  to  be  the  aggrec/aUve  centres 
of  sensation  ;  and  local  lesion  (apoplectic  clot,  tumor,  softening, 
etc.)  in  or  near  them  is  frequently  associated  with  hemiplegia, 
etc.  The  paralysis  is  (iommonly  observed  (from  decussation  of 
the  nerve  iibres  in  the  medulla  oblongata  and  cord)  on  the  side 
opj)osite  to  that  on  wr.icli  the  lesion  has  occurred. 

2.  Subjective  impressions  and  sensations;  i.  e.,  those  which 
affect  the  consciousness  of  the  individual  without  the  action  of  any 
external  or  •peripheral  cause.  These  subjective  impressions  may  be 
divided  into — a,  those  which  are  central  in  their  origin,  as  when 
disease  of  the  thalamus  causes  neuralgia  of  the  fifth  pair  of 
nerves ;  and  6,  those  whose  origin  is  intermediate ;  as,  when  in- 
flammation of  the  slirath  of  a  nerve,  or  disease  of  the  spinal  axis, 
gives  rise  to  pain  referred  by  the  patient  to  the  termination  of  the 
nerve. 

Subjective  hypersBsthesia,  or  perversion  of  sensibility  or  psychi- 
cal impressibility,  maybe,  in  its  causation  (as  regards  the  nervous 
apparatus),  either  functional  ^  or  organic  ;  and  the  difference  be- 
tween these  is  often  practically  important. 

3.  Muscular  Paralysis ;  or  that  condition  in  which  a  central 
volition  (or  an  excitation  equivalent  to  it)  fails  to  produce  its 
normal  effect  of  muscular  contraction.  Of  this  defect,  also,  the 
pathological  origin  may  be,  as  to  its  seat,  either  peripheral,  inter- 
mediate, subcentral  (in  the  corpora  striata  or  cerebellum),  or 
central  (in  the  convolutions  of  the  cerebrum).  Muscular  as  well 
as  sensational  paralysis  dependent  on  an  affection  of  the  brain, 
occurs  usually  (not  invariably)  on  the  opposite  side  to  that  of  the 
encephalic  lesion.  Scarcely  ever  is  palsy  confined  exclusively  to 
sensation  or  to  voluntary  motion — altbough  the  proportion  of  im- 
pairment of  the  two  functions  may  vary  considerably  in  particular 
cases.  Both  kinds  are  occasionally  re/?ex  (Brown-Sequard).  In- 
vestigation is  now  being  industriously  made  into  the  pathogeny 
(morbid  origination)  of  motor  as  well  as  of  sensory  paralysis,  by 
means  of — 1,  minute  anatomical  dissection;  2,  comparison  of  lesions 
found  after  death  with  symptoms  occurring  during  life  ;  3,  vivi- 
sectory  experiynentation.  To  my  judgment  it  appears,  that  the 
"net  result"  of  experimentation  upon  the  brain  and  spinal  cord 
of  living  animals  during  the  last  twenty  years,  has  been  to  throw 

1  FiincUonal  nervous  disorder  results  fjenerally  (Todd)  from  an  abnormal  state  of  thfl 
blood.    See  a  valuable  lecture  ou  Hyperiesthesia,  by  Dr.  C.  Handfield  Jones  :  Brit.  Med. 
Journ.,  Sept.  30,  1871. 
6 


62  GENERAL    PATHOLOGY. 

the  whole  subject  into  inextricable  confusion.  While  a  quite 
different  estimate  of  it  prevails  generally  in  the  profession,  it  is 
admitted  by  several  excellent  authorities  that  normal  and  morbid 
anatomy^  taken  together  with  the  study  of  the  healthy  and  dis- 
ordered performance  of  functions^  afford  at  present  the  most  reliable 
information  required  by  the  physician  for  his  guidance.^ 

4.  Involuntary  contraction  of  voluntary  muscles,  or  Convulsion. 
Only  very  local,  and  usually  transitory  spasmodic  affections  are 
(unless  reflex)  peripheral  in  their  origin.  Usually,  convulsive 
affections  are  accounted  for  by  functioaal  excitement  of  the  motor 
centres ;  the  causation  of  which  is  made  up  of  three  elements, 
in  variable  proportion,  viz. :  a,  morbid  irritability  of  the  spinal 
excito-motor  apparatus  itself;  6,  imperfect  control  over  the  subordi- 
nate nervous  centres  by  the  brain,  from  an  abnormal  condition  of 
the  latter ;  c,  the  disturbing  influence  of  a  peripheral  irritant 
— as,  tension  of  the  gums  in  teething,  worms  in  the  bowels,  un- 
digested food  in  the  stomach,  etc. 

The  three  forms  of  spasmodic  disturbance  to  which  the  muscles 
are  liable  under  a  morbid  alteration  of  innervation,  viz.,  the  tonic, 
choreic,  and  clonic,  are  illustrated  respectively  in  tetanus,  chorea, 
and  epilepsy.  Modifications  of  these  are  seen  also  in  spastic  spinal 
paralysis,  locomotor  ataxia,  and  paralysis  agitans  (shaking  palsy). 
Hughlings-Jackson  has  shown  that  chronic  localized  convulsions 
(affecting  a  few  muscles  only),  as  well  as  localized  paralysis, 
usually  result  from  localized  lesion  of  the  opposite  hemisphere  of 
the  brain — most  generally  a  tumor. 

5.  Excito-secretory  action  (Longet,  Campbell)  becomes  morbid 
under  conditions  like  those  which  produce  convulsion ;  for  ex- 
ample, the  diarrhcea  of  infants,  so  common  at  the  time  of  dentition. 

A  subject  of  great  interest,  ahnost  neglected  until  within  the 
last  dozen  years,  is  that  of  the  effects  of  various  agencies,  through 
the  nerve-centres,  upon  the  blood-vessels.  But  while  the  vaso- 
motor nerves  are  now  recognized,  and  their  special  relation  to  the 
ganglionic  or  sympathetic  system  is  beginning  to  be  appreciated, 
much  confusion  on  this  subject  still  pervades  physiological  and 
medical  hterature. 

A  further  important  pathological  subdivision  exists  as  to  the 
method  of  origination  of  those  functional  disturbances  of  the 
nervous  system  to  which  we  have  been  alluding. 

The  source  of  any  of  the  above  forms  of  nervous  disorder, 
hypersesthesia,  anaesthesia,  muscular  paralysis,  or  convulsion, 
may  be  (when  not  purely  local)  either — 

1.  Central  organic  disease  ; 

2.  Blood-perversion,  or  defective  nutrition ; 

3.  Purely  sympathetic  disturbance. 

It  is  far  from  easy,  in  many  cases,  to  mark  the  diagnosis 
petween  these  different  modes  of  causation  of  nervous  symptoms  ; 
wut,  when  the  decision  has  been  made  in  any  iustance,  the  prog- 
nosis is  most  favorable  in  the  last  case  ;  less  so  in  the  second ;  and 
most  unfavorable  in  %\ie,  first,  i.  e.,  when  the  symptoms  have  their 
origin  in  an  actual  organic  lesion  of  au  important  nerve-centre. 

1  To  justify  the  above  expressions,  let  any  one  compare  the  earlier  and  later  dicta  of 
Pr.  Brown-Sequard,  one  of  the  most  eminent  of  living  experimental  physiologists. 


NEURO-PATHOLOGY.  63 

6.  Neurasthenia  is  a  torm  convoniontly  applied  (Beard)  to  a 
general  deficiency  of  tone  ;ind  strenij;th  in  the  nervous  system ; 
producing  symptoms  variously  affecting  either  the  organic,  sen- 
sory, muscular,  or  psychical  functions.  If  the  first  of  these  be 
most  involved,  we  have  nervous  dyspepsia,  occasionally  diarrlicea, 
or  vrmiithifj ;  amenorrJiopd,  dysmenorrhoea,  or  menorrhagia;  perhaps 
retention  of  urine,  etc.  When  the  sensory  apparatus  exhibits  the 
results  of  neurasthenia,  neuralgia  is  tlie  most  common  symptom  ; 
sometimes,  however,  ancesthesia  occurs  instead,  or  functional  poraZ- 
ysis  of  special  sensation;  e.  g.,  blindness  or  deafness.  In  the  mus- 
cidar  apparatus,  the  same  condition  produces  a  tendency  to  con- 
vulsions, general  or  local.  Psychical  symptoms  of  neurasthenia 
are  extremely  various  in  both  sexes.  In  females,  all  of  the  above 
disorderly  conditions  and  actions  have  been  commonly  grouped 
together,  under  the  term  hysteria.  But  they  occur  in  men  and 
boys  also,  under  circumstances  sustaining  the  view  that  in  either 
sex  the  relation  to  the  reproductive  system  is  rather  accidental 
than  essential.  Special  terms  have  been  invented  to  apply  to 
some  of  the  mental  peculiarities  of  neurasthenic  subjects  ;  as 
anthropophohia^  dread  of  society  ;  agoraphobia,  a  fear  of  crossing 
large  open  spaces  ;  thanatopjhohia.,  an  excessive  apprehension  of 
death  ;  to  which  might  be  added  ergopjhohia,  or  morbid  shrinking 
from  active  eflbrt  of  every  sort,  etc.  But  these  expressions  add 
very  little  to  definiteness  of  description.  Undoubtedly,  neuras- 
thenia bears  an  increasingly  large  part  in  the  diseased  states  with 
which  the  physician  has  to  deal  in  the  artificial  life  of  modern 
society,  especially  in  great  cities.  Cattses  of  neurasthenia  are  chiefly 
as  follows  :  sexual  or  sensual  excesses  or  abuses  ;  very  large  use  of 
tobacco;  continued  "worry,"  i.e.,  fretting  and  wearing  care 
about  business,  domestic,  political,  or  other  affairs  ;  too  laborious 
brain-work,  with  insufficiency  of  sleep  ;  social  dissipation,  with 
the  same  effect  of  deficiency  of  rest ;  unhygienic  habits  of  bodily 
and  mental  inertia,  typified  by  the  corset,  the  veil,  the  novel,  and 
the  sofa.  Predisposition  to  nervous  debility,  with  some  or  all  of 
its  attendant  ailments,  is,  be3^ond  question,  often  hereditary.  It 
is  promoted,  sometimes,  by  inheritance  of  the  gouty  constitution. 

No  more  interesting  question  has  been  latterly  discussed  in 
neuro-pathology,  than  that  of  the  localization  of  brain-lesions. 
Physiological  experiment  and  pathological  anatomy  have  contrib- 
uted many  facts  concerning  it ;  in  the  former  field,  through  the 
labors  especially  of  Fritsch,  Hitzig,  Terrier,  Schiff,  Nothnagel, 
Carville,  Duret,  Burdon  Sanderson,  Brown-Srquard,  Lussana, 
Yulpian,  Munk,  Tamburini,  Dupuy,  and  Lauterbach  ;  in  the  lat- 
ter (morbid  anatomy),  by  those  of  Dax,  Bouillaud,  Broca,  Hugh- 
lings-Jackson,  Charcot,  Bouchard,  Pitres,  Brun,  Lupine,  Mey- 
nert,  Huguenin,  Mills,  and  others. 

Space  cannot  be  given  here  for  a  full  statement  upon  this  sub- 
ject.' My  own  view  upon  the  physiological  inquiry  is  this  :  that 
aU  that  has  been  proved  is,  the  functional  association,  in  some 


1  See  a  summary  account  of  it  by  the  author,  in  Reynolds'  System  of  Medicine,  Ameri- 
can edition,  Vol.  I.,  p.  916  el  seq. 


64 


GENERAL   PATHOLOGY. 


manner,  not  yet  fully  determined,  of  certain  regions  of  the  cortex 
of  the  cerebral  hemispheres  with  diiferent  groups  of  muscles  ; 
that  this  relation  is  probably  connected  particularly  with  emo- 


FiG.  18. 


Lateral  View  of  Brain,  showing  Fissures  and  Convolutions. 
Fig.  19. 


Inner  Surface  of  Hemisphere,  showing  Convolutions  and  Fissures. 

a,  superior  frontal  fissure ;  b,  inferior  frontal ;  c,  fissure  of  Rolando ;  d,  fig- 
sure  of  Silvius;  e,  interparietal;  /,  fronto-parietal ;  g,  parieto-occipital ;  h, 
first  temporo-sphenoidal ;  i,  second  ditto ;  j,  inferior  ditto ;  k,  occipito-tem- 
poral;  Z,  calcarine  ;  m,  hippocampi. 

A,  superior,  or  first  frontal  convolution  ;  B,  second  ditto  ;  C,  third  ditto ;  D, 
ascending  frontal;  E,  ascending  parietal ;  F,  superior  parietal ;  Fj,  prcecuneus; 
G,  supra-marginal;  G-^,  gyrus  angularis,  or  pli  courbe;  H,  first  temporo- 
sphenoidal  ;  I,  second  ditto ;  J,  third  ditto ;  K,  fusiform  lobule ;  L,  lingual 
lobule ;  M,  gyrus  fornicatus ;  Mj,  gyrus  hippocampi ;  Mg,  uncus  gyri  fornicati, 
or  subiculum  cornu  Ammonis;  N,  cuneus.     (From  Bristowe.) 


NEU  UO-PATHOLOGY. 


65 


tiondl  expression;  Terrier's  phrase,  '■'■psycho-motor  "  centres,  bcine: 
thus  most  appropriate  ;'  while,  under  organic  disease  or  injury  of 
the  same  regions,  the  motor  functions  which  are  directly  con- 
trolled by  the  lower  sensori-motor  centres  (thalamus,  corpus  stri- 
atum, pons,  medulla  oblongata,  etc. )  are  often  perturbed  or  im- 
paired by  reflex  action  or  synqjatky.  Goltz  has  removed  the  whole 
of  the  ^'- motor  zone"  of  the  cortex  cerebri  in  animals,  without 
paralysis  of  motion  following. 

Fig.  20. 


Lateral  View  of  Brain,  showing  Ferrier's  Psycho-motor  Centres. 

I,  centre  of  lateral  movements  of  head  and  eyes,  with  elevation  of  eyelids 
and  dilatation  of  pupils  ;  II,  extension  of  arm  and  hand  ;  III,  complex  move- 
ments of  arm  and  leg,  as  in  climbing,  swinging,  etc.;  IV,  movements  of  leg 
and  foot  as  in  locomotion ;  V,  movements  of  lips  and  tongue,  as  in  articula- 
tion ;  VI,  depression  of  angle  of  mouth ;  VII,  elevation  of  angle  of  mouth ; 
VIII,  supination  of  hand  and  flexure  of  forearm;  IX,  centre  of  platysma, 
retraction  of  angle  of  mouth ;  X,  movements  of  hand  and  wrist;  XI,  centre 
of  vision;  XII,  centre  of  hearing;  XIII  (Fig.  20),  centre  of  touch;  XIV 
(Fig.  20),  centre  of  smell  and  taste.     (From  Bristowe.) 

The  most  considerable  amount  of  pathological  evidence  in 
regard  to  cerebral  localization  of  function,  is  that  which  points 
to  the  third  anterior  frontal  convolution  of  the  left  hemisphere, 
as  the  seat  of  language.  Many  cases  have  been  observed  in  which 
a  lesion  of  that  part  of  the  cortex  cerebri  has  been  found  to  accom- 
pany right  hemiplegia  (paralysis  confined  to  the  right  half  of  the 
body)  and  apjhasia  (see  Aphasia^  later  in  this  volume).  But  the 
whole  subject,  both  of  the  physiology  and  the  pathology  of  the 
brain,  is  rendered  more  difficult  by  the  very  close  interconnection, 
in  structure  and  function,  existing  amongst  its  different  parts  ; 
making  it  often  almost  or  quite  impossii)le  to  separate  from  each 
other  the  direct  and  indirect  effects  of  injury  or  disease.     An 


1  Ferrier,  however,  claims  a  more  positive  motor  function  for  these  "  centres"  than 
appears  to  me  to  be  warranted  by  the  facts ;  especially  in  view  of  the  results  of  Goltz'a, 
Dupuy's,  and  Tamburini's  experiments. 

6*  E 


66  SEMEIOLOGY. 

immense  amount  of  care  and  labor  will  still  be  necessary,  before 
accuracy  of  diagnosis  in  aflFections  of  the  brain  can  be  based  upon 
a  complete  and  exact  pathology. 

Some  further  attention  will  be  given  to  cerebral  localization,  in 
connection  with  the  special  pathology  of  the  Brain  and  Nervous 
System,  in  Part  II.  of  this  book. 

Localization  of  diseases  affecting  the  spinal  marrow  has,  of  late 
years,  through  clinical  observation,  aided  by  autopsic  study,  ac- 
quired considerable  definiteness.  Romberg,  Duchenne,  Lockhart 
Clarke,  Charcot,  Tiirck,  Westphal,  Erb,  Gowers,  Moxon,  Seguin, 
and  Hamilton  have  especially  contributed  to  this  result.  Anatom- 
ical names  are  now  commonly  given  to  diseases  of  the  spinal 
marrow  :  as,  posterior  spinal  sclerosis^  for  locomotor  ataxy  ;  lateral 
spinal  sclerosis,  for  spastic  spinal  paralysis  ;  anterior  poliomyelitis, 
for  infantile  paralysis  ;  disseminated  or  multiple  cerebrospinal  scle- 
rosis,^ etc. 

MODES  OF  DEATH. 

Death  may  occur — 

1st.  By  asthenia ;  the  dynamic  force  of  the  system  being  ex- 
hausted or  destroyed,  so  that  the  heart  ceases  to  beat ;  as  in  death 
from  old  age,  lightning-stroke,  poisoning  by  prussic  acid,  etc. 
Syncope  (fainting)  simulates  or  threatens  this. 

2d.  By  anaemia ;  the  blood  being  rendered  insufficient  for  life ; 
as  from  hemorrhage  after  labor,  surgical  injuries,  bursting  of  an 
aneurism,  etc. 

3d.  By  apnoea,  or  asphyxia ;  that  is,  arrest  of  respiration,  either 
from  disease  of  the  lungs,  obstruction  of  the  air-passages,  defi- 
ciency or  impurity  of  the  air. 

4th.  By  coma;  the  brain  (medulla  oblongata)  being  made  inca- 
pable of  sustaining  innervation ;  as  in  apoplexy,  opium  poison- 
ing, etc. 

Sudden  death  may  occur  from 

Apoplexy ; 

Valvular  heart-disease  (especially  mitral); 

Rupture  of  the  heart  (or  syncope)  in  fatty  degeneration  ; 

Bursting  of  an  aneurism,  or  abscess,  within  the  thorax,  or  of 
an  aneurism  within  the  abdomen  ; 

Suffocation ; 

Violent  shock  or  alarm,  producing  fatal  syncope. 


SECTION  II. 

SEMEIOLOGY. 

I.  RATIONAL  SYMPTOMATOLOGY. 
II.  PHYSICAL  DIAGNOSIS. 

Rational  symptoms  and  physical  signs  are  distinguished  (some- 
what arbitrarily)  thus:  a  rational  symptom  is  a  sign  of  disease 
which  is  obvious  to  the  patient  himself  or  to  the  practitioner  with- 
out close  inspection.   A  physical  sign  is  one  determined  by  exam- 

1  See  Part  II.  for  the  special  pathology  of  these  affections. 


SYMPTOMATOLOGY.  67 

ination  into  the  properties  and  material  conditions  of  the  organs 
of  the  body ;  as  by  palpation,  auscultation,  percussion,  etc. 
Symptoms  guide  us,  generally,  hy  yhysioloyical  inference;  physi- 
cal signs,  by  anatomical  necessity. 

Symptoms  and  pliysical  signs  together  contribute  to  diagnosis ; 
t.  e.,  tlie  knowledge  of  the  character  of  the  morbid  process  or 
state  in  a  given  case  ;  the  answer  to  the  question,  "Wliat  is  the 
matter  ?  " 

Prognosis  is  the  anticipation  of  the  progress  and  results  or  ter- 
minations of  disease.  The  essential  elements  of  prognosis  are,  a 
knowledge  of  the  cause  or  causes  of  disease  present ;  of  tlie  condi- 
tio^i  of  the  organs;  and  of  the  general  vital  state,  or  degree  of  vital 
force  of  the  system.  Prognosis  depends,  therefore,  upon  diagnosis ; 
but  is  governed,  in  a  majority  of  cases,  chiefly  by  those  rational 
symptoms  which  indicate  the  organic  energy  of  the  patient,  and 
the  kind  and  rate  of  change  .that  his  system  is  undergoing. 

SYMPTOMATOLOGY. 

Symptoms,  or  rational  signs,  are — 

Local,  or  constitutional ; 

Idiopathic  (primary),  or  secondary  ; 

Premonitory  (prodromata) ; 

Critical ; 

Pathognomonic  (characteristic). 
"We  examine  the  symptoms  of  disease  as  connected  with  the 
digestive,  circulatory,  respiratory,  tegumentary,  secretory,  motor, 
sensory,  and  psychical  apparatus. 

SYMPTOMS   CONNECTED  WITH  THE  DIGESTIVE  STSTEBI. 

The  tongue  may  be  natural,  pale,  cold,  red,  furred,  brown, 
black,  cracked,  or  fissured. 

It  is  pa^e,  in  anaemia. 

Cold,  in  collapse,  as  of  cholera,  etc. 

Hed,  in  scarlatina,  stomatitis,  sometimes  in  gastritis. 

Furred,  in  indigestion,  gastro-hepatic  catarrh,  fever,  etc. 

Brown  or  blacky  cracked  or  fissured,  in  low  fevers  :  as  typhus  or 
typhoid. 

Protruded  with  difficidty,  in  low  fevers,  and  in  apoplexy ;  to  one 
side,  in  paralysis. 

The?)ia»ne>v>/'cZeam«(/of  the  tongue  during  convalescence  should 
also  be  noticed,  as  affording  prognostic  indications. 

The  teeth  are  covered  with  sordes  in  low  febrile  states. 

They  are  loosened  by  severe  salivation. 

Their  raind  decay  shows  some  impairment  of  constitution  ;  but 
this  is  unfortunately  very  common. 

The  gums  are  swollen,  soft,  and  spongy,  and  prone  to  bleed,  in 
scurvy. 

A  blue  line  along  the  gums  is  observed  in  lead  poisoning. 

A  red  line  along  their  edge  is  sometimes  noticed  in  phthisis. 

Swelling  and  soreness  of  the  gums,  with  tenderness  of  the  teeth, 
and  a  coppery  taste,  occur  in  salivation. 

Increased  flow  of  saliva  gives  name  to  this  effect  of  mercury  on 


68  SEMEIOIiOGY. 

the  mouth.   Jaborandi  often  produces  it,  without  any  action  upon 
the  gums.     Iodide  of  potassium  occasionally  does  so. 

Deficiency  and  thickness  or  viscidity  of  the  saliva  occur  gener- 
ally during  fever ;  and  often  also  in  chronic  diseases,  especially 
of  the  throat  and  stomach. 
The  taste  is  morbidly 
Bitter^  in  hepatic  derangements,  dyspepsia,  etc. ; 
Sour^  in  gastric  indigestion; 

Saltish^  in  phthisis  pulmonalis,  haemoptysis,  etc. ; 
Putrid^  in  gangrene  of  the  lungs. 
Appetite  is  generally  deficient  (anorexia)  in  disease,  especially 
of  an  acute  character. 

Excessive  appetite  (bulimia)  is  not  often  important;  sometimes 
it  occurs  in  nervous  affections,  in  diabetes^  and  in  persons  having 
worms  in  the  alimentary  canal. 

Perverted  appetite  is  one  of  the, symptoms  of  chlorosis,  hys- 
teria, etc. 

Thirst  is  excessive  in  tioo  opposite  conditions:  high  fever  and  low 
collapse. 
Difficulty  of  swallowing^  [dysphagia]  may  result  from — 
Inflammation  of  the  fauces,  tonsils,  or  pharynx ; 
Spasmodic  constriction  of  the  throat ; 
Stricture  of  the  pharynx  or  oesophagus ; 
Obstruction  by  a  foreign  body,  tumor,  etc. ; 
Betro-pharyngeal  abscess; 
Paralysis,  as  after  diphtheria ; 
General  debility,  as  in  the  moribund  state. 

Nausea  and  vomiting  may  occur  from — 

Indigestion:  egesta,^  partly  digested  food,  mucus,  etc.; 

Colic:  eg.  ditto,  bile,  etc.; 

Sea-sickness:  ditto,  ditto; 

Pregnancy:  eg.,  mucus,  food,  etc. ; 

Gastritis:  eg.,  abundant  and  altered  mucus,  etc. ; 

Hysteria:   eg.,  gastric  and  biliary  secretions,  more  or  less 

altered ; 
Cholera  morbus:  eg.,  gastric  and  biliary  secretions,  diluted; 
Cliolera  maligna:  eg.,  copious  watery  fluid  (rice-water) ; 
Bilious  fever:  eg.,  altered  mucus,  bile,  etc. ; 
Yellow  fever:  eg.,  (advanced  stage)  black  vomit; 
Ulcer  of  stomach:  eg.,  mucus,  lymph,  blood; 
Cancer  of  stomach:  eg.,  ditto,  with  cancer-cells,  fibres,  etc.; 
Disease  of  the  brain:  eg.,  not  peculiar  in  character; 
BrighVs  disease  of  kidney:  eg.,  not  peculiar; 
Strangulated  hernia:  eg.,  stercoraceous  (fecal) ; 
Poisoning:  as  by  tartar  emetic,  arsenic,  etc. 

Sarcince,  or  microscopic,  wool-sack  like  vegetable  parasites  are 
occasionally  found  in  matters  vomited,  in  cases  of  disease  of  the 
stomach.  Epithelial  cells,  starch  granules,  torulse  (also  vegetable), 
and  vibriones,  are  often  discovered  by  the  microscope. 

1  Egesta,  matters  thrown  out. 


SYMPTOMS CIRCULATORY    SYSTEM.  69 

SYMPTOMS  CONNECTED  WITH  THE  CIRCULATORY  SYSTEM. 

Palpitation  or  disturbed  action  of  the  heart  may  depend 
upon — 

Pericarditis  or  endocarditis ; 

Hninrtroplui  of  the  heart;- 

Chronic  valvular  disease; 

Exophthalmic  goitre; 

Ancemia; 

Nervoiis  irritability  (nervousness); 

Disoixler  of  the  brain ; 

Dyspepsia. 

The  pulse  should  be  examined  when  the  mind  and  body  of  the 
patient  are  as  tranquil  as  possible.  It  is  most  rapid  in  the  stand- 
ing posture,  less  so  when  sitting,  slowest  in  the  recumbent  posi- 
tion. Dr.  Guy  asserts  it  to  be  most  rapid  in  the  morning.  It  is 
increased  in  force  and  frequency  by  exercise,  food,  and  emotional 
excitement.  The  pulse  of  the  female  is  slightly  more  rapid,  as  a 
rule,  than  that  of  the  male  sex.  It  diminishes  in  rapidity  from 
infancy  to  old  age ;  but  in  very  aged  people  it  again  becomes 
somewhat  accelerated. 

In  obscure  cases  we  should  examine  the  pulsation  of  other  arte- 
ries beside  those  at  the  wrist ;  and  should  especially  observe  the 
character  of  the  impulse  of  the  heart.  Absence  of  pulsation  in  a 
particular  artery  is  often  important  as  a  sign  of  embolism.^ 

In  adults,  the  average  number  of  beats  in  health  is,  for  the 
male,  70  ;  for  the  female,  75. 

Infancy,  120  to  100.  Middle  Hfe,  75  to  65. 

Childhood,  100  to  90.  Old  age,  70  to  60. 

Youth,  90  to  75.  Decrepit  age,  75  to  80. 

We  judge  by  the  pulse  (inferentially)  of  the  force  of  the  heart's 
action,  of  the  force  of  the  arterial  impulse,  of  the  excitability  of 
the  nervous  system,  of  the  fulness  of  the  blood-vessels,  and  of  the 
tone  and  physical  condition  of  the  arteries. 

The  pulse  in  disease  may  be  natural,  or  strong,  weak,  firm,  yield' 
ing,  full,  small,  bounding,  compressible,  rapid,  slow,  quick,  jerking, 
hard,  soft,  tense,  gaseous,  corded,  wiry,  thready,  imperceptible,  regu- 
lar, irregular,  intermittent,  dicrotous. 

Not  considering  it  necessary  here  to  define  each  of  these  terms, 
it  may  be  i-emarked  that  an  important  difference  exists  between 
a  rapid  pulse  and  a  quick  pulse,  and  between  one  that  is  merely 
full  and  large  and  one  that  is  strong. 

The  pulse  of  fever  is  characterized  by  moderate  acceleration, 
with  variable  increase  of  force  in  the  beat.  It  is  most  rapid  in 
relapsing  fever,  scarlet  fever,  and  puerperal  fever. 

The  pulse  of  inflammation  (with  constitutional  excitement)  is 
not  only  accelerated,  but  hard  or  tense,  and  commonly  full.  What- 
ever may  be  said  to  the  contrary,  this  character  of  the  pulse  is, 
in  acute  inflammations,  of  great  consequence  as  one  indication  for 
treatment;  although,  of  course,  it  must  not  be  depended  on  alone. 

^  Bee  Embolism,  in  Part  II. 


70  SEMEIOLOGY. 

The  pulse  of  nervous  irritation  is  usually  quick,  and  variable 
in  rapidity  and  force,  under  excitement  or  repose, 

A  jerking^  abrupt  pulse  is  associated  (Stokes,  Corrigan)  with 
deficiency  of  the  aortic  valve  of  the  heart. ' 

The  pulse  oi  extreme  debuity  is  nearly  always  (as  in  the  dying 
state)  very  rapid  and  very  small,  or  "  thready,"  A  pulse  of  150 
or  160  in  an  adult  is  nearly  always  a  fatal  sign. 

Slowness  of  the  pulse  is  most  marked  in  compression  of  the 
hrain  (as  from  fracture  of  the  skull,  apoplectic  clot,  or  hydro- 
cephalic effusion)  and  in  opium  poisoning.  Exceptionally,  it  is 
met  with  under  other  circumstances.  In  one  case,  I  have  known 
the  pulse  to  be  but  20  in  the  minute  (temporarily)  from  func- 
tional disorder  of  the  heart. 

Irregularity  of  the  pulse  is  occasionally  congenital;  sometimes 
it  comes  on  with  old  age.  It  is  of  the  least  importance  in  young 
children.  It  may  be  a  transient  symptom,  accidental,  as  it  were, 
during  the  progress  of  an  acute  malady;  or  at  the  commencement 
of  convalescence,  as  from  remittent  fever.  It  is  directly  related  to 
the  nature  of  the  disease,  in  certain  cases  of  disease  of  the  heart, 
and  in  meningitis  (inflammation  of  the  membranes  of  the  brain) 
during  the  stage  of  effusion.  Dr.  B.  W.  Richardson  has  laid  stress 
upon  the  frequency  with  which  mental  depression  is  a  cause  of 
irregularity  of  the  heart's  action. 

The  dicrotOTis  or  double  pulse  is  observed  especially  during  con- 
tinued fevers,  either  typhous  or  typhoid.  It  is  explained  in  some 
cases,  at  least,  by  a  loss  of  muscular  tone  in  the  arteries,  so  that 
the  arterial  impulse  is  separated  from  that  of  the  ventricles  by  a 
perceptible  (though  slight)  interval. 

The  state  of  the  capillary  and  venous  circulation  often  affords 
signs  of  disease.  Torpor  of  the  circulation  is  marked  by  slowness 
in  the  return  of  the  blood  after  it  has  been  displaced  by  pressure; 
for  instance,  upon  the  cheek  or  back  of  the  hand.  The  veins  of  the 
hand  or  arm  may  be  similarly  examined  with  advantage  ;  as  in 
cholera,  pernicious  intermittent,  low  continued  fever,  etc.  The  venous 
circulation  is  affected  not  unfrequently  in  heart  disease:  e.  g.,  pul- 
sation of  the  jugular  veins,  from  valvular  disease  involving  the 
right  side  of  the  heart;  cyanosis,  or  hlueness,  from  imperfect  sepa- 
ration of  the  arterial  from  the  venous  blood,-  etc.  A  network  of 
enlarged  superficial  abdominal  veins  is  sometimes  seen  in  cirrhosis 
of  the  liver. 

Pulsation  of  the  veins  does  not  always  depend  upon  disorder  of 
the  heart.  The  author  has  seen  three  cases  in  which  jugular  pul- 
sation was  evidently  the  result  of  local  irritatimi,  exaggerating  the 
muscular  activity  resident  in  the  organic  muscle-fibres  of  the  vein. 

The  blood  itself  is  perhaps  the  most  important  of  all  subjects 
of  inquiry  in  connection  with  disease.  Little,  however,  as  yet,  is 
known  of  its  morbid  changes.     The  principal  facts  are,  that — 

In  anaemia,  there  is  deficiency  of  haemoglobin  and  corpuscles  ; 

In  plethora,  an  excess  of  red  corpuscles ; 

In  leucocythmmia,  an  excess  of  the  colorless  corpuscles ; 

In  pseudo-leukaemia,  deficiency  of  red  corpuscles ; 

1  Galabin  has  shown  (Medico-Chirurgical  Transactions,  1876)  that  occasionally  this 
pulse  results  from  relaxation  of  arterial  tension. 


SYMPTOMS — CIRCULATORY    SYSTEM,  71 

In  inflammation^  and  in  chlorosis^  excess  of  fibrin ; 

In  antidpation  of  suppuration,  excess  of  colorless  corpuscles ; 

In  gout,  excess  of  uric  acid ; 

In  rheuyvatism  (probably),  excess  of  lactic  acid; 

In  (malarial)  mekmo'.mia,  excess  of  free  pigment; 

In  jauyuUce,  excess  of  biliary  matter  ; 

In  advanced  BrighVs  disease,  excess  of  urea,  etc.  (urajmia) ; 

In  diabetes,  excess  of  sugar  ; 

In  malignant  cholera,  deficiency  of  water  and  salts; 

In  relapsing  fever,  spirilla  (minute  organisms) ; 

In  yellow  fever,  granulation  of  white  corpuscles. 

These  peculiarities  require  minute  inspection,  with  the  aid  of 
the  microscope  or  of  chemical  reagents.  To  the  eye,  differences 
sometimes  exist  which  may  be  instructive;  e.  g.,  as  to  the  bright 
red  or  very  dark  color  of  the  blood  ;  as  to  the  magnitude,  form, 
and  firmness  of  the  clot,  the  rapidity  of  coagulation,  etc. 

Counting'  the  blood-corpuscles  is  important  in  the  diagnosis  of 
leukcemia  (leucocythsemia)  and  pseudo-leiikcemia,  progressive  per- 
nicious avcemia,  etc. 

The  principle  employed  was  first  devised  by  Vierordt ;  it  con- 
sists in  making  a  definite  dilution  of  a  measured  quantity  of  blood, 
and  counting  the  corpuscles  in  a  known  volume  of  that  dilution. 
Cramer,  Potain,  Malassez,  Hayem,  Nachet,  and  Gowers  have 
modified  Vierordt's  process. 

Gowers  gives  the  following  account  of  his  improvement  upon 
Hayem's  hcemacytometer^  His  apparatus  consists  of  "  1.  A  small 
pipette,  holding  exactly  995  cubic  millimetres.  2.  A  fine  capil- 
lary tube,  holding  5  cubic  millimetres.  3.  A  small  glass  jar,  in 
which  the  dilution  is  made.  4.  A  cell,  exactly  one-fifth  of  a 
millimetre  deep,  the  floor  of  which  is  ruled  intenth  of  a  millimetre 
squares.  Whatever  solution  is  employed,  the  corpuscles  are, 
more  or  less,  changed  by  it.  One  which  answers  very  well  is  a 
solution  of  sulphate  of  soda  of  a  specific  gravity  of  1025. 

"A  pipetteful  of  the  solution  is  placed  in  the  mixing  vessel. 
Five  cubic  millimetres  of  blood  are  drawn  into  the  capillary  tube 
from  a  drop  in  the  finger,  and  then  blown  into  the  solution.  The 
two  are  well  mixed  by  a  glass  rod;  a  drop  of  the  dilution  is  placed 
in  the  centre  of  the  cell,  the  covering  glass  is  applied  and  secured 
by  springs,  and  the  slide  is  placed  on  the  stage  of  the  microscope. 
The  lens  is  then  focussed  to  the  squares.  In  a  few  minutes  the 
corpuscles  have  sunk  on  to  the  squares.  The  number  in  ten 
squares  is  then  counted."  Multiplying  the  average  number  for  a 
square,  of  these  ten  micrometric  squares,  by  10,000,  we  obtain  the 
number  of  corpuscles  for  a  cubic  millimetre  of  blood.  In  healthy 
blood,  Vierordt  and  Welcker  found  this  number  to  be  5,000,000 ;  of 
which  from  5,000  to  15,000  are  white  or  colorless  corpuscles.  In 
leukcemia  and  pernicious  anaemia  the  red  and  white  corpuscles  are 
both  diminished  in  number  ;  but  in  leuki38mia  the  white  corpus- 
cles are  notably  increased  in  number  beyond  the  normal  propor- 
tion. Cases  of  this  last  affection  not  rarely  show  as  many  as  1 
white  corpuscle  to  3  of  the  red.     In  Hodgkin's  disease  (pseudo- 

1  Reynolds'  System  of  Medicine,  American  edition,  Vol.  III.,  p.  520. 


72  SEMEIOLOGY. 

leukaemia)  the  alteration  of  the  normal  proportion  is  very  seldom, 
if  ever,  so  great. 

In  cases  of  lingering  prostration,  cZots  may  form  in  the  heart 
or  large  arteries  before  death.  After  very  rapid  malignant  dis- 
eases, the  blood  is  sometimes  found  uncoagulable. 

Hemorrhag'e  from  different  parts  of  the  body  is  often  impor- 
tant as  a  symptom,  but  requires  to  be  interpreted  with  care.  Its 
consequence  varies  much  with  its  quantity,  and  the  source  of  the 
blood  thrown  out. 

Thus,  in  epistaxis,  or  bleeding  at  the  nose,  the  flow  may  result 
from — 

Mechanical  injury ; 

Congestion  of  the  Schneiderian  membrane; 

Congestion  of  the  brain; 

Typhoid  fever  ; 

Hemorrhagic  diathesis; 

Suppressed  menstruation. 

This  variety  of  hemorrhage  is,  however,  most  frequent  during 
childhood  and  early  adolescence. 

In  haemoptysis,  or  spitting  of  blood,  the  source  of  the  hemor- 
rhage may  be  the — 

Gums; 

Posterior  nares; 

Throat  (e.  g.,  ulcerations,  etc.); 

Bronchial  mucous  membrane; 

Lungs  ; 

Stomach. 
In  the  last  case,  being  vomited  into  the  mouth,  it  is  properly 
called  hsematemesis.  Sometimes  it  requires  care  to  determine 
what  is  the  source  of  blood  coming  from  the  mouth.  We  must 
notice  what  are  the  symptoms  preceding  the  hemorrhage;  and  the 
manner  of  its  ejection,  whether  by  coughing  or  vomiting,  etc.,  as 
well  as  tlie  appearance  of  the  blood,  wliether  mixed  with  food, 
gastric  fluid,  etc. 
True  pulmonary  haemoptysis  may  arise  from — 

Active  congestion  of  the  lungs ; 

Passive  congestion,  from  heart  disease; 

Tubercular  phthisis; 

Hemorrhagic  diathesis; 

Vicarious  monthly  flow,  in  the  female ; 

Mechanical  injury,  as  fractured  rib,  etc. ; 

Rupture  of  aortic  aneurism.^ 
Haematemesis,  or  vomiting  of  blood,  may  be — 

Hysterical ; 

Ulcerative ; 

Cancerous ; 

Vicarious,  etc. 
"Uterine  hemorrhage,  other  than  the  normal  menses,  may  be — 

1  Dr.  Baelz,  of  Japan,  has  reported  cases  of  hasmoptysis  from  the  presence  in  the 
lungs  of  a  minute  gregarinoid  parffsi^e.  Epistaxis  has,  in  like  manner,  been  sometimes 
caused  by  a  small  parasite  in  the  nasal  cavities  ;  pentastoma  iosnioides. 


SYMPTOMS llESPIRATOKY    ORGANS.  73 

Cnnrjestive ; 
Ulcerative  ; 
Cancerous;  as  well  as,  in  tho  prerjnant  female,  placentaL 

technically  called  "unavoidable  hemorrhage;"  that  of 

abortion.;  or  after  parturitvm. 

Hemorrhage  from  the  bowels  may  be  connected  with— 
Hemorrhoids,  or  piles  ; 
Dysentery ; 

iflceration  of  the  bowels; 
Intussusception ; 
Cancer  of  rectum,  etc. ; 
JRupture  nf  aneurisrii ; 
Hemorrhagic  diathesis ; 
Typhoid  or  yellow  fever ; 
Vicarious  menstruation. 

Haematuria,  or  bloody  urine,  may  result  from  — 

Mechanical  injury  of  the  bladder,  prostate  gland,  or  urethra; 

Itenal  inflammation; 

Calculus ; 

Hemorrhagic  diathesis ; 

Passive  senile  congestion  of  the  kidneys ; 

Scarlatina. 

SYMPTOMS  CONNECTED  WITH  THE   RESPIRATORY  ORGANS. 

The  normal,  average  rate  of  breathing  in  the  adult,  while  at 
rest,  is  sixteen  or  eighteen  respirations  in  the  minute.  In  fever 
it  is  much  accelerated.  In  extreme  narcotism  it  becomes  slower 
than  natural.  In  some  cases  of  fatty  degeneration  of  the  heart  it  is 
sighing  and  interrupted. 

Dyspnoea,  or  difficulty  of  breathing,  when  great,  is  called 
orthopnoea,  from  the  erect  posture  required  by  the  patient.  Cer- 
vical respiration,  i.  e.,  auxiliary  action  of  the  muscles  of  the 
neck,  occurs  in  cases  of  great  exhaustion,  or  of  obstruction  of 
the  respiratory  function  by  disease. 
Dyspnoea  may  be  caused  by — 

Chlorine  or  other  irrespirable  gases  in  the  air; 

Morbid  change  of  the  blood,  as  in  cholera  ; 

Laryngeal  or  tracheal  obstruction,  as  in  croup,  etc. ; 

Bronchial  spjasmodic  constriction,  as  in  asthma ; 

Bronchitis;  pneumonia;  pleurisy ;  pjhthisis; 

Heart  disease;  aneurism  of  thoracic  aorta; 

Cancer  within  the  chest ;  hydrothorax ;  ascites. 
Coughing  may  depend  upon  a  variety  of  causes,  the  nature  of 
which  may  often  be  concluded  upon  from  its  character.     Thus, 
usually, 

Cough  is  dry  and  hollow,  or  hacking,  when  nervous  or  sym- 
pathetic ; 

Dry  and  tight,  in  early  bronchitis ; 

Soft,  deep,  and  loose,  in  advanced  bronchitis ; 

Hacking,  in  incipient  phthisis  pulmonalis  ; 

Deep  and  distressing,  in  confirmed  consumption  ; 

Short  and  sharp),  in  pneumonia ; 

7 


74  SEMEIOLOGY. 

Barking  and  hoarse,  in  early  or  spasmodic  croup ; 
Whistling,  in  advanced  membranous  croup  ; 
Paroxysmal,  and  whooping,  in  pertussis. 

Expectoration  is— 

Mucous,  in  catarrh,  and  early  bronchitis  ; 
Purulent,  in  severe  and  protracted  bronchitis ; 
Busty,  in  early  and  middle  stages  of  pneumonia ; 
Bloody  and  muco-purulent,  in  phthisis  ; 
nummular  and  heavy,  etc.,  in  advanced  phthisis  ;^ 
Putrid,  in  gangrene  of  the  lung. 
The  temperature  of  the  breath  is  increased  during  the  febrile 
state.     It  is  lowered,  sensibly,  only  in  aggravated  prostration ;  as 
in  the  collapse  of  cholera.     Coldness  of  the  breath  is  an  almost 
certain  prognostic  of  dissolution. 

The  odor  of  the  breath  is  rarely  perfectly  agreeable  except  in 
the  healthy  infant  or  child.  It  is  very  heavy  at  the  commence- 
ment of  fever ;  sour  during  indigestion ;  offensive,  often,  from 
decayed  teeth  ;  rotten,  in  gangrene  of  the  lung. 

Hiccoug'h  (singultus)  is  produced  by  a  spasm  of  the  diaphragm. 
It  may  depend  upon  indigestion,  nervous  disorder,  or  exhaustion. 
It  is  serious  in  prognosis  only  when  the  last  (exhaustion)  is 
present  or  is  anticipated. 

Stertorous  respiration,  from  relaxation  of  the  velum  palati, 
results  from  cerebral  oppression ;  the  cause  of  which  may  be  apo- 
plexy, fracture  of  the  skull,  dead  drunkenness,  or  narcotism  by 
opium,  etc. 

SYMPTOMS  CONNECTED  WITH  THE  TEGUMENTART  APPARATUS. 

The  skin  is  hot  and  dry  during  the  presence  of  fever. 
Moisture  is  almost  always  a  favorable  sign. 
The  exceptions  are,  the  profuse  colliquative  sweats  of  phthisis, 
etc.,  and  the  cold  and  clammy  perspiration  of  extreme  prostra- 
tion.    Coldness   of  the   skin,   or  inequality  of  temperature,   is 
always  more  or  less  unfavorable. 

Emaciation  is  often  an  important  sign.  It  generally  occurs  in 
severe  chronic  diseases,  but  is  sometimes  rapidly  brought  on  in 
acute  affections ;  e.g.,  diarrhcea  or  dysentery.  The  changes  which 
occur  in  the  adipose  tissue,  and  in  the  plumpness  and  roundness, 
or  flabbiness  and  shrunken  appearance  of  the  surface  of  the  body, 
are  often  extremely  rapid  in  children. 

The  color  of  the  skin  varies  much  in  disease.  Thus,  the  face 
is — 

Pale,  in  anaemia,  syncope,  etc. ; 

Flushed,  in  fever,  congestion  of  brain,  etc. ; 

Cheeks  brightly  flushed,  in  hectic  fever ; 

Forehead  and  eyes  flushed,  in  early  stage  of  yellow  fever ; 

Purple  or  livid,  in  low  continued  fever ; 

Yellow,  in  jaundice,  bilious  fever,  yellow  fever ; 

Sallow,  in  chlorosis,  dyspepsia,  cancer ; 

Bronzed,  in  Addison's  disease  ; 

1  Microscopic  examination  discovers  portions  of  disintegrated  lung-tissue  in  the  expec- 
toration of  phthisical  patients;  arched  and  anastomosing  fibrils  of  pulmonary  and 
bronchial  elastic  tissue,  with  abrupt  or  square  fracture. 


SYMPTOMS  —  URINATION.  75 

Blue,  in  the  collapse  of  cholera,  and  in  cyanosis  ; 
Black,  almost,  in  asphyxia,  and  I'rom  large  internal  use  of 
nitrate  of  silver. 
Eruptions  upon  the  skin  are  characteristic  of  certain  diseases. 
Their  description  belongs  to  Special  Patholog}'.     (See  Part  II.) 

SYMPTOMS   CONNECTED  WITH  THE  SECRETIONS. 

These  must  always  be  considered  along  with  othei-  explanatory 
symptoms  ;  and  the  character  of  the  discharges  should  never  be 
overlooked.     Thus, 
Constipation  may  denote — 

Tor])or  of  the  muscular  coat  of  the  bowels  ; 

Deficient  secretion  of  the  liver,  or  intestinal  glands  ; 

Defective  innervation,  from  spinal  or  encephalic  disease  ; 

Siriciure  of  rectum  or  colon  ;  preynancii ;  cancer ; 

Intussusception,  strangulated  hernia,  etc. ; 

Symxjathetic  disturbance  from  fever,  etc. ; 
Diarrhoea  and  Dysentery  will  be  considered  in  another  depart- 
ment. It  may  be  mentioned,  however,  that  in  di/sentery  the  dis- 
charges contain  blood,  mucus,  lymph  (in  small  quantity),  and, 
when  ulceration  has  occurred,  pus.  In  diarrhoea  they  are  either 
fecal,  mucous,  bilious,  or  serous^the  last  being  of  importance, 
especially  in  the  diagnosis  of  cholera. 

Symptoms  Connected  with  Urination. 
Djisuria,  or  difficult  urination  (strangury). 
Ischuria,  retention  of  urine. 
Enuresis,  incontinence. 

Diuresis  (diabetes),  excessive  discharge  of  urine. 
Iforbid  character  of  the  urine  itself. 

The  average  quantity  of  urine  passed  by  a  healthy  adult  in 
twenty-four  hours,  is  from  thirty  to  fifty  ounces — greatest  in  the 
winter. 

In  reaction  to  test-paper,  the  urine  is  normally  acid;  redden- 
ing litmus,  or  restoring  to  turmeric  its  yellow  color  after  it  has 
been  made  brownish-red  by  an  alkali. 
The  color  of  healthy  urine  is  that  of  amber. 
The  average  specific  gravity  of  human  urine  (water  being  1000) 
is  1017-24 ;  containing  about  twenty  grains  of  solid  matter  to  the 
ounce. 

Deviation,  to  a  certain  extent,  from  any  or  all  of  the  above 
standards  as  to  quantity,  reaction,  color,  and  weight,  is  quite 
compatible  with  ordinary  health ;  but  a  very  decided  and  per- 
sistent deviation  is  a  proof  of  disease. 
Retention  of  urine  may  be  caused  by — 

Deficiency  of  contractile  pjower  in  the  bladder ; 
Spasmodic  constriction  of  the  vesico-urethral  muscular  fibres ; 
True  stricture  of  the  urethra ; 
Enlargement  of  the  prostate  gland ; 
Calculus  in  the  bladder  or  urethra ; 
Percussion  and  palpation,  as  well  as  catheterism,  are  some- 
times necessary  to  determine  the  fact  of  retention  of  urine. 


76  SEMEIOLOGY. 

Suppression  of  urine,  from  inaction  of  the  kidneys,  is  a  most 
serious  symptom  under  all  circumstances.  If  long  continued,  it 
becomes  fatal  by  uroemic  poisoning — coma,  and  often  convulsions, 
preceding  death.  Partial  suppression  of  urine  occurs,  sometimes 
transiently,  in  cholera,  scarlet  fever,  etc. 

Excessive  urination  is  frequently  present  in  hysterical  cases — 
the  water  being  pellucid,  and  of  low  specific  gravity  (diabetes 
insipidus).  The  influence  of  cold  and  of  diuretic  medicines  pro- 
duces a  similar  watery  excess,  mostly  with  little  increase  in  the 
solids  of  the  urine. 

Diabetes  mellitus  is,  however,  a  more  important  affection ;  in 
which  the  urine  is  not  only  excessive  in  quantity,  but  heavy,  and 
loaded  vnth  sugar. 

For  the  accurate  estimation  of  the  changes  occurring  in  the 
urine  in  disease,  scientific  skill  is  requisite.  To  pursue  original 
investigatio^is  upon  the  subject,  considerable  practical  knowledge 
of  analytical  chemistry,  and  of  the  use  of  the  microscope,  is  indis- 
pensable. But  for  the  application  of  the  conclusions  of  pathologi- 
cal chemists  and  micrologists  to  diagnosis,  a  much  more  moderate 
amount  of  skill  will  suffice.  There  is  wisdom  in  the  remark  of 
Dr.  Todd  [Clin.  Led.  on  Urinary  Organs,  etc.,  p.  73),  that,  "while 
it  is  clearly  a  duty  not  to  neglect  any  means  of  observation  and 
investigation,  it  is  desirable  that  you  should  be  as  little  as  possi- 
ble dependent  on  means  which  are  not  always  at  hand,  and  which 
it  does  not  fall  to  the  lot  of  every  eye  and  hand  to  use  with  equal 
readiness  and  skill.  "^ 

I  shall  state,  on  this  principle,  only  the  most  important  and 
available  points  in  urinary  pathology  and  diagnosis. 

Allowance  must  always  be  made,  or  correction  obtained,  for 
the  variation  the  urine  undergoes  in  the  course  of  the  same  day. 
It  may  be  divided  conveniently  into  the  uriiia  sanguinis,  urina 
chyli,  and  urina  potus :  the  first  being  that  after  a  night's  rest, 
the  second  that  after  dinner,  the  third  after  a  very  light  meal 
with  fluid,  as  tea.  All  of  these  should  in  each  case  be  examined 
and  compared.^ 

The  questions  in  regard  to  any  given  specimen  of  urine  are,  as 
to  its  general  appearance,  specific  gravity,  acidity  or  alkalin- 
ity, the  chemical  or  microscopical  character  of  its  sediments, 
and  the  effects  of  reagents  upon  the  clear  fluid. 

General  appearance.  If  clear,  after  standing  a  few  hours, 
note  the  color.  Deep-colored  transparent  urine,  of  high  specific 
gravity,  indicates  excessive  metamorphosis  of  tissue.  In  jaun- 
dice, the  urine  is  generally  very  yellow,  and  sometimes  as  dark 
as  porter. 

If  the  urine  be  opaque,  it  is  either  white  or  dark.  White  opaque 
urine  contains  either  mucus,  or  pus,  or  undissolved  earthy  salts,  or 
all  of  these  together.  Mucus  floats  more  distinctly  in  a  separate 
cloud  than  pus  ;  purulent  urine  is  generally  opaque  throughout, 

1  A  similar  remark  has  been  made  by  Virchow,  in  reference  to  "naked-eye  pathol- 
ogy." He  asserts  that  almost  always  microscopical  appearances  may  be  anticipated  by 
a  careful  and  skilful  examination  with  the  unaided  sight. 

2  It  is  well  also  (in  some  cases  at  least)  to  avoid  the  complication  of  urethral  di.scharges, 
by  having  the  first  ounce  or  two  passed  into  a  ditferent  vessel  from  that  which  is  to 
receive  the  urine  to  be  retained  for  examination. 


SYMPTOMS  —  URINATION. 


77 


and  of  a  creamy  yellow  color  at  bottom.  Pus  can,  however,  be 
more  readily  diHuscd  by  agitation  than  mucus.  Purulent  urine 
is  oftenest  acid;  mucous  uriiu;,  generally  alkaline.  Pus  contains 
albumen,  as  shown  by  testing ;  mucus  does  not.  Acetic  acid 
coagulates  mucus,  not  pus. 
Dark-colored  opaque  urine  is  most  frequently  tinged  with  blood, 

Fig.  21. 


Foreisrn  Bodies  in  Urine. 


a.  Cotton  fibres ;  b.  Flax  fibres ;  c.  Hairs ;  d.  Air-bubbles ;  e.  Oil  globules ; 
/.  Wheat  starch  ;  g.  Potato  starch ;  h.  Rice  starch ;  i,  i,  i.  Vegetable  tissue ; 
k.  Muscular  fibres. 

giving  it  a  pinkish  or  brownish  hue.  The  latter  color  prevails 
especially  in  cases  of  passive  hemorrhage  from  the  kidney — the 
former  in  fresh  hemorrhage  from  the  bladder,  or  active  renal  hem- 

7* 


78  SEMEIOLOGY. 

orrhage.  Urine  may  also  be  dark  from  the  presence  of  bile  (as 
in  jaundice),  or  of  purpurin ;  also,  from  carbolic  acid  poisoning. 

For  biliary  coloring  matter  (biliphain,  cliolepyrrhin)  a  good  test 
is  (Gmelin's)  the  addition  of  nitric  or,  better,  nitroso-nitric  acid, 
drop  by  drop,  to  a  little  of  the  urine  on  a  white  dish.  It  will 
become  pale  green,  violet,  pink,  and  yellow,  in  succession.  Or 
(Heller's)  shake  a  little  solution  of  albumen  (white  of  egg)  with 
the  urine,  and  then  add  a  slight  excess  of  nitric  acid ;  if  bile  be 
present,  the  coagulum  will  be  dull  green  or  bluish.  Or  (Cunisset) 
add  half  its  bulk  of  chloroform  to  "the  urine  ;  the  yellow  coloring 
matter  will  be  carried  down. 

Pettenkofer^s  test  for  the  biliary  acids  (rarely  present  in  urine) 
consists  in  the  addition  (after  separating  albumen,  if  it  be  present 
in  the  urine,  by  coagulation  and  filtration)  to  the  fluid,  of  a  grain 
or  two  of  white  sugar,  and  then,  drop  by  drop,  two-thirds  of  the 
volume  of  strong  sulphuric  acid.  If  bile  be  present,  a  very  dis- 
tinct and  characteristic  violet-red  color  will  be  produced,  which 
is  intensified  by  heat.  Strassburg,  of  Bremen,  modifies  this  by 
dipping  a  slip  of  filtering  paper  into  the  urine,  to  which  a  little 
cane  sugar  has  first  been  added.  The  slip  is  then  withdrawn  and 
dried.  On  applying  to  it  a  drop  or  two  of  concentrated  sulphuric 
acid  by  means  of  a  glass  rod,  and  holding  the  paper  up  to  a  strong 
light,  a  violet  color  appears. 

MarechaVs  test  for  bile  is  tincture  of  iodine,  allowed  to  trickle, 
a  drop  at  a  time,  down  the  side  of  a  test-tube  containing  the  fluid 
to  be  examined.  A  green  color  will,  if  biliary  coloring  matter  be 
present,  appear  just  below  the  portion  reddened  by  the  iodine. 
This  test  is  probably  as  reliable  as  any  other. 

Purpurin  is,  probably,  a  morbid  modification  of  the  coloring 
matter  of  urine,  derived,  originally,  from  that  of  the  blood.  Some 
pathologists  believe  it  to  be  one  of  the  indications  of  disease  of 
the  liver.  It  frequently  accompanies  deposits  of  urate  of  ammo- 
nium. Urine  containing  purpurin  is  pink  or  purple,  not  unlike 
bloody  urine  in  appearance. 

As  tests  —  liquor  potassse  makes  purpurin  greenish-brown;  car- 
bonate of  potassium,  yellow.  Alcohol  will  dissolve  purpurin  from 
an  evaporated  extract  of  urine,  receiving  and  retaining  its  color. 
Hydrochloric  acid  added  to  urine  containing  purpurin  will,  if 
heat  be  applied,  give  it  a  lilac  or  decidedly  purple  tinge. 

Late  authors  make  little  mention  of  purpurin.  Tyson^  states 
the  normal  coloring  matters  of  the  urine  to  be  urohoematin  (uro- 
phain)  and  uroxanthin  (indican) ;  abnormal,  besides  foreign  mat- 
ters from  food  or  drink,  the  coloring  principles  of  the  blood  (altered) 
and  uroerythrin  (Heller). 

Excess  of  urohcematin  may  occur  in  fevers,  or  whenever  the 
urine  is  much  concentrated  ;  also  in  jaundice  and  in  chronic  dis- 
eases of  the  liver.  Heller's  test  for  urohsematin  is,  pouring  a  fine 
stream  of  the  urine  from  a  height  of  four  inches  into  a  small 
quantity  of  pure  colorless  sulphuric  acid.  A  deep  garnet-red 
coloration  results  from  the  admixture.  (Diabetic  sugar,  how- 
ever, and  also  uroerythrin,  give  the  same  reaction.) 

1  Practical  Examination  of  Urine,  Philadelphia,  1875,  p.  57. 


SYMPTOMS — URINATION.  79 

Excess  of  uroxanthin  ovindican  has  been  observed  in  a  number 
of  diseases  :  cancer  of  the  liver,  cancer  of  the  stomach,  phthisis, 
tabes  mesenterica,  Addison's  disease,  spinal  and  renal  affections, 
etc.  Heller's  test  for  it  is,  dro])pin<f  and  stirring  ten  or  twenty 
drops  of  the  urine  into  a  small  quantity  of  pure  hydrochloric 
acid.  A  small  amount  of  ihdican  will  give  a  pale,  yellowish-red 
color ;  a  large  amount,  a  violet  or  blue  coloration.  This  is 
intensified  (Senator)  by  adding  a  few  drops  of  a  concentrated 
solution  of  chloride  of  calcium.' 

Uroerythrin  is  present  in  the  "lateritious" 'sediment  of  the 
urine  in  fevers.  It  is  also  precipitated,  when  in  solution  in  the 
urine,  by  acetate  of  lead,  producing  a  pink  deposit. 

In  the  so-called  "malarial  heematui'ia"  of  severe  Southern 
fevers,  Berenger-Feraud  asserts  the  proof  that  choluria  really 
exists,  the  urine  being  colored  not  by  blood,  but  by  bile. 

Alcohol  is  present  in  the  urine  when  an  excess  of  it  has  been 
taken  into  the  system.  Anstie's  test  for  it  is  one  part  of  bichro- 
mate of  potassium  with  three  hundred  parts  of  sulphuric  acid, 
giving  a  green  color,  more  or  less  intense,  according  to  the 
amount  of  alcohol  in  solution. 

Black  urine  has  been  sometimes  seen  as  the  result  of  poisonous 
over-doses  of  chlorate  of  potassium.  Urine  is  dark  also  fas  already 
said)  or  green,  when  carlolic  acid  is  being  largely  eliminated. 
Por  the  latter  the  best  test  is  Sonnenburg's.  It  depends  on  the 
conversion  of  the  sulphates  of  the  urine  into  soluble  sulpho-car- 
bolates.  A  portion  of  the  urine  to  be  examined  is  acidulated 
with  strong  acetic  acid,  and  then  an  excess  of  chloride  of  barium 
is  added.  With  normal  urine  this  will  produce  a  copious  pre- 
cipitation of  sulphate  of  barium.  When  much  carbolic  acid  is 
present,  almost  no  precipitate  falls. 

Salicylic  acid  (or  sodium  salicylate)  should  be  found  in  the  urine 
during  its  medicinal  administration.  If  not  thus  eliminated  (as 
when  excretion  is  prevented  by  disease  of  the  kidne3's),  its  toxic 
accumulation  may  be  apprehended.  For  salicylic  acid,  tincture 
of  perchloride  of  iron  is  a  delicate  test.  When  a  few  drops  of 
it  are  added  to  the  urine,  if  salicylic  acid  be  present,  a  bright 
violet  color  (salicyluric  acid)  will  be  produced. 

The  specific  gravity  of  urine  is  easily  ascertained  by  means 
of  the  urinometer,  a  small  glass  instrument  so  weighted  and 
marked  that,  when  floated  in  the  urine  at  60°  Falir.,  it  will  show, 
in  thousandths,  the  excess  of  its  density  above  that  of  water. 

Excessive  weirjht  of  the  urine  is  caused  by  its  containing  an 
unusual  quantity  of  scdts  or  of  urea,  or  by  sugar.  The  quantity 
passed  in  twenty-four  hours  must  always  be  considered  in  con- 
nection with  its  specific  gravity;  so  as  to  judge  of  the  actual 
quantity  of  the  solids  passed,  as  well  as  their  degree  of  dilution. 

The  heaviest  urine  is  that  of  diabetes  mellitus  (glycosuria),  some- 
times reaching  1060  to  1070.  The  lightest  is  observed  in  hysteria 
and  in  Bright's  disease,  running  down  sometimes  even  to  1003. 

The  degree  of  acidity  of  urine  may  be  approximately  estimated 
by  the  more  or  less  decided  redness  given  by  it  to  litmus  paper. 

1  Centralblatt  Med.  Wiss.,  No.  20, 1877. 


80 


SEMEIOLOGY. 


If  it  be  alkaline,  it  will  make  turmeric  brown  and  restore  the  blue 
to  litmus  reddened  by  an  acid.  A  highly-animalized  diet  in- 
creases the  acidity  of  the  urine.  Vegetable  food,  without  Any 
meat,  may  reduce  it  even  to  a  neutral  condition. 

Fig.  22. 


Urea. 


Alkalinity  of  the  urine  is  uncommon,  unless  (Bence  Jones)  im- 
mediately after  a  meal.  If  it  does  occur  at  other  times,  it  depends 
upon  either  fixed  (potassa,  soda)  or  volatile  alkali  (ammonia).  If 
the  former,  it  is  usually  associated  with  nervous  debility  or  general 


Fig.  23. 


Uric  Acid. 


Uric  Acid. 


depression  of  vital  power,  except  when  accounted  for  by  the 
medicinal  use  of  potassa,  soda,  or  lithia.  Excess  of  the  phosphatic 
salts,  and  of  oxalate  of  calcium  (oxaluria),  often  accompanies  alka- 
linity of  the  urine.  The  importance  of  the  presence  of  oxalate 
of  calcium  has  probably  been  overrated.    Garrod  and  Parkes  have 


SYMPTOMS URINATION, 


81 


shown  reason  for  believing  that  a  little  oxalic  acid  exists  naturally 
in  the  blood,  and  Learcd  and  Duckworth  have  caused  arti- 
ficial oxaluria  by  the  free  ingestion  of  lime-water  into  the 
stomach. 

Carbonate  of  ammnnimu.,  when  present  in  the  urine,  causes  it 
to  effervesce  on  the  addition  of 

an  acid,  from  the  escape  of  car-  Fir,.  24. 

bonic  acid  gas.  The  change  of 
color  produced  by  ammonia  in 
turmeric  paper  will,  also,  disap- 
pear when  it  is  heated. 

Ammoniated  urine  becomes 
so  by  the  decomposition  of  urea, 
and  its  conversion  into  carbo- 
nate of  ammonium.  When  the 
bladder  is  inflamed  and  contains 
unhealthy  mucus,  this  decompo- 
sition occurs,  either  in  the  blad- 
der or  in  the  urine  shortly  after 
it  has  passed,  making  it  alkaline 
in  reaction,  and  effervescent 
when  acid  is  applied.  In  cases 
of  much  less  frequency^  urine  will 
effervesce  with  acid  from,  the 
presence  of  carbonate  of  calcium. 

The  odor  of  urine  is  apt  to  be  most  intense  when  tissue-change 
is  going  on  rapidly,  and  the  quantity  of  fluid  passed  is  small,  its 
density  being  then  high.  Excess  of  phosphates  is  sometimes 
accompanied  by  a  fetid  odor.  A  sweetish  smell  may  be  perceived 
in  diabetic  urine.  Some  articles  of  food,  especially  asparagus, 
and  certain  medicines,  as  oil  of  turpentine,  cubebs,  and  copaiba, 
give  their  own  odor  to  the  urine. 

Sediments  occur  in  the  urine,  either  when  first  passed  or  after 
standing,  from  its  containing  substances  (1)  insoluble  in  it,  or 

Fig.  25. 


Carbonate  of  Calcium, 
acid. 


Ilippiiric 


Octahedral  Oxalate  of  Calcium  Crystals.        Dumb-bell-shaped  Crystals 
(Bowman.)  of  Oxalate  of  Calcium. 

(Bowman.) 

(2)  precipitated  upon  its  cooling,  or  (3)  resulting  from  chemical 
changes  rapidly  taking  place.  Such  sediments  may  be  examined 
both  chemically  and  microscopically. 

A  faicn-colored  deposit,  not  crystalline,  which  is  redissolved  when 
the  urine  is  heated^  consists  of  urates  of  ammonium  and  sodium. 

F 


82 


SEMEIOLOGY, 


Urate  of  ammonium  is  also  immediately  dissolved  by  solution 
of  ammonia  or  of  potassa. 

A  much  more  rare  deposit,  of  cystine,  has  a  similar  color,  but 
it  is  not  soluble  by  heat,  and  is  but  slowly  dissolved  by  alkalies. 
Cystine,  under  the  microscope,  shows  rosette-like  or  hexagonal 
crystals,  sometimes  like  those  of  chloride  of  sodium ;  the  latter, 
however,  is  much  the  most  soluble  in  water.  The  crystals  of 
"triple  phosphate"  are  known  from  those  of  cystine  by  being 
freely  soluble  in  dilute  acids. 

Heavy  red  sand,  at  the  bottom  of  the  vessel,  insoluble  in  hydro- 
chloric acid,  but  dissolved  by  nitric  acid  and  also  by  alkalies  (as 
liquor  potassse),  is  uric  (lithic)  acid.  When  strong  nitric  acid  is 
added  to  deep-red  urine  containing  urate  of  ammonium  in  excess 
with  purpurin,  solution  occurs,  with  effervescence,  and  a  brownish 
deposit  falls,  of  uric  acid  chiefly.  When  evaporated  to  dryness, 
the  addition  of  ammonia  to  the  deposit  will  produce  the  purple 
murexide.  Similar  reactions  occur  with  uric  acid  itself,  acted  upon 
by  strong  nitric  acid. 


Fig.  27. 


Fig.  28. 


Crystals  of  Tyrosin  obtained  by  the  evapora- 
tion of  urine.     (Frericlis.) 


Crystals  of  Leucin.     (Beale.) 


Blood-corpuscles  sometimes  fall  to  the  bottom  of  urine  as  a 
colored  sediment.  They  are  not  soluble  in  acids  or  alkalies,  and 
may  be  distinguished  by  aid  of  the  microscope. 

A  whitish  deposit,  not  at  all  dissolved  hy  heat,  but  dissolved  by 
nitric  acid,  consists  of  earthy  salts,  phosphatic  or  oxalic.  If 
oxalate  of  calcium,  it  will  not  be  dissolved  by  acetic  acid  ;  if  phos- 
phates, that  acid  will  render  the  liquid  clear.  Phosphatic 
deposits  occur  (even  if  not  excessive  in  amount)  when  the  urine 
is  alkaline.  Nevertheless,  excess  of  the  phosphates  is  indi- 
cated by  the  urine  becoming  turbid  when  heated,  and  clear- 
ing up  when  acetic  acid  is  added. 

A  creamy-white  flocculent  and  ropy  deposit,  not  dissolved  on 
agitating  the  liquid,  is  probably  mucus.  A  greenish-yellow  set- 
tling, diffused  when  shaken,  and  which  is  dissolved  by  and  forms 
a  jdly  with  liquor  potassse,  may  be  concluded  to  be  pus.^ 

The  microscope  may  detect,  even  in  urine  scarcely  opaque,  or 
in  its  residue  after  evaporation — 


1  Dr.  Day,  of  Geelong,  tests  for  pus  with  a  fluid  prepared  by  exposing  a  saturated 
alcoholic  solution  of  guaiacum  to  the  air  until  it  has  absorbed  oxygen  enough  to  cause 
it  to  become  green  with  iodide  of  potassium.  A  dnip  or  two  of  this  will  give  a  clear 
blue  color  with  a  very  small  amount  of  pus  moistened  with  water. 


S  Y  M  r  T  O  M  S  —  U  li  I  N  A  T  I  ()  N  .  83 

Blood-corpuscles,  disk-like,  or  jagGjed  and  out  of  shape  ; 

Mucus-coriMscles,  mingled  witli  epithelial  scales  or  cells  ; 

Pus-corpuscles,  granular,  containing  several  nuclei  ; 

Epithelial  cells  or  scales,  from  the  kidney  or  bladder  ; 

Tubular  casts  from  the  kidney  (desquamative  nephritis)  ; 

Spermatozoa;  thread-like,  with  one  end  ovate  and  expanded  ; 

Uric  acid  crystals,  variously  shaped,  as  lozenges  and  square 
prisms ; 

Triple  phosphate  of  magnesium  and  ammonium,  in  three-sided 
prisms  with  beveled  ends  ; 

Phosphate  of  calcium,  granular,  or  in  long  needle-shaped  crj'stals ; 

Oxalate  of  calcium,  in  transparent  octahedral  or  dumb-bell  crys- 
tals ; 

Oil-globules  (rare),  with  dark,  smooth,  and  well-defined  out- 
line; 

Chyle-corpuscles,  found  in  urine  of  a  milky  appearance. 

Several  of  these  forms  will  be  noticed  hereafter  in  connection 
with  particular  diseases.  The  following  summary  statement  con- 
cerning casts  in  the  urine  is  from  Dr.  J.  Tyson  :  ^ 

"  1.  Hyaline  casts  are  found  in  all  forms  of  Bright's  disease,  as 
well  as  in  temporary  congestions  of  the  kidney,  active  or  pas- 
sive.'^ 

"  2.  Epithelial  casts  are  found  in  acute,  subacute,  and  chronic 
parenchymatous  nephritis.  In  the  latter  two  forms  the  cells 
are  generally  degenerated  and  fragmentary. 

"3.  Blood  casts  are  found  in  acute  parenchymatous  nephritis, 
and  where  hemorrhages  have  occurred  in  the  kidneys. 

"4.  Pale  granular  casts  are  found  in  interstitial  nephritis  (con- 
tracted kidney)  and  chronic  parenchymatous  nephritis. 

"5.  Dark  granular  casts  are  found  in  parenchymatous  nephritis, 
acute  and  chronic,  and  rarely  in  interstitial  nephritis. 

"  6.  Waxy  casts  are  found  only  in  chronic  Bright's  disease,  and 
attend  either  of  the  three  principal  forms. 

"  7.  Oil  casts  are  found  in  subacute  and  chronic  forms  of  Bright's 
disease,  and  may  attend  any  of  the  three  principal  forms,  but 
are  most  numerous  in  chronic  parenchymatous  nephritis  (fatty 
kidney)." 

Urine  free  from  deposit  should,  in  suspected  cases,  be  tested 
for  albumen  and  for  sugar. 

The  best  test  for  albumen  is  the  successive  addition  to  the  urine 
of  heat  and  nitric  acid.  If  it  become  and  continue  turbid  under 
their  combined  influence,  it  is  albuminous ;  but  neither  alone 
will  suflice.  Another  test  (Millon's)  is  the  acid  nitrate  of  mer- 
cury ;  which  causes  with  albuminous  urine  a  pink  precipitate. 
Fibrin  and  casein  have  this  reaction  also,  but  they  will  scarcely 
ever  be  found  in  urine,  in  the  absence  of  albumen.  Other  min- 
eral salts  (ferrocyanide  of  potassium,  bichloride  of  mercury,  etc.) 
will  precipitate  albumen ;  but  the  first-mentioned  test  is  the 
most  available. 

iPhila.  Med.  Times,  March  13,  1880,  p.  294. 

2  Hyaline  casts  are  (Curschmana,  ISSO)  stained  ultra-marine  blue  by  methyl  (green 
methyl  aniline).  Med.  Times  and  Gazette,  April,  1880,  from  Virchow's  Archiv.,  vol. 
Ixxix. 


84: 


SEMEIOLOG  Y 


Picric  acid  ^  has  been  somewhat  used.  A  drop  of  the  urine  to 
be  tested,  falliug  into  picric  acid,  if  albumen  be  present,  will 
make  a  white  streak  through  it.  A  dark  background  will  render 
this  more  evident.  Bowditch  has  proved  this  to  be  a  less  deli- 
cate process  for  the  purpose  than  that  with  heat  and  nitric  acid. 

Fig.  29. 


Nitrate  of  Urea. 

We  must  remember,  however,  that  albummuria  is  no  longer 
synonymous  with  Bright's  disease.  Albumen  occurs,  transientlyj 
in  the  urine  of  many  acute  afleetions,  as  scarlatina,  diphtheria, 
and  renal  congestion  from  cold  and  wet.  It  is  only  when  persistent 
as  a  symptom  that  it  becomes  pathognomonic  of  degeneration  of 
the  kidneys.  In  rare  instances,  moreover,  this  degeneration  has 
been  found  (post-mortem)  to  exist  without  albuminuria. 

The  principal  tests  for  diabetic  sugar^  (glucose)  are  Moore''s, 
Trommer''s,  Maimienfs^  Bdttge7'\s,  and  fermentation. 

Moore''s :  Boil  the  liquid  with  half  its  bulk  of  liquor  potassse.' 
If  saccharine,  it  will  become  first  yellow  and  then  brown,  and 
ruby  red  by  transmitted  light.  Addition  of  a  few  drops  of  nitric 
acid  (Heller)  will  cause  the  brown  color  to  disappear. 

Trammer'' s :  Add  a  few  drops  of  strong  solution  of  sulphate  of 
copper  to  the  urine  in  a  test-tube,  and  then  pour  in  liquor 
potasses  to  about  half  the  bulk  of  the  urine.  On  the  careful 
application  of  heat,  a  yellowish  or  reddish-brown  precipitate 


1  Gazette  Medicale  de  Paris,  1873,  p.  122. 

2  Bence  Jones  has  found  a  very  small  quantity  of  grape  sugar  in  healthy  urine. 

3  Dr.  M.  Tidy  (Med.  Times  aud'Gazette,  June  3, 1871)  prefers  this  test  for  the  approxi- 
mate determination  of  the  gunnt.Hy  of  sugar  in  diabetic  urine.  A  series  of  solutions  is 
prepared,  each  containing  a  ditferent  amount  of  grape  sugar  (say  from  one-fourth  of  a 
grain  up  to  two  grains),  but  all  the  same  amount  of  potassa.  The  difference  of  the  tint 
is  well  marked.  In  testing  the  urine,  a  solution  of  1  grain  of  potassa  to  every  7  grains 
of  water  is  made ;  of  this  70  grains  are  added  to  70  grains  of  the  urine  ;  boil  one  minute, 
dilute  with  distilled  water  in  a  4  oz.  vial  (similar  to  those  used  for  the  test  solutions), 
and  then  compare  with  the  solutions  containing  known  quantities  of  sugar,  until  the 
exact  tiut  is  found. 


SYMPTOMS URINATION, 


85 


(suboxide  of  copper)  is  thrown  down.  Fehli7ig\s  test  fluid  is 
analogous  to  this.  As  modified  by  Lowe,  it  consists  of  sulpliate 
of  copper,  witli  soda  and  a  little  glycerin.'  Boil  the  test-solution, 
and  add  the  suspected  urine  drop  by  drop. 

For  the  detection  of  small  quantities  of  sugar,  Dr.  W.  Koberts 
advises  that  the  test  be  applied  in  the  following  way  :  "Heat  in 
a  test-tube  two  fluidraclnns  of  Pehling's  standard  solution  of 
copper,  and  when  boiling,  add  five  to  ten  drops  of  the  urine  to 
be  tested  ;  if  sugar  be  abundant,  as  in  a  decidedly  diabetic  urine, 
a  yellowish  or  brick-red  opacity  and  deposit  will  be  produced. 
If  no  such  reaction  ensue,  test  for  traces  of  sugar  by  adding  one 
and  a  half  tluidrachms  of  the  urine  to  the  hot  liquid,  heat  again 
to  ebullition,  and  set  aside  for  some  time.  If  no  milkiness  is 
produced  as  the  mixture  cools,  the  urine  is  either  quite  free  from 
sugar,  or  at  any  rate  contains  less  than  ^^  of  one  per  cent.  If 
the  quantity  of  sugar  is  very  small,  namely,  from  i  to  5^5  of  one 
per  cent.,  the  precipitation  of  the  yellow  or  red  cuprous  oxide 
does  not  take  place  immediately,  but  occurs  after  some  time,  as 
the  liquid  cools,  and  the  manner  of  the  change  is  peculiar.  First, 
the  mixture  loses  its  transparency,  and  passes  from  a  clear  bluish 
green  to  a  light  greenish  opacity,  looking  just  as  if  some  drops 
of  milk  had  fallen  into  the  tube.     This  green  milky  appearance 

Fig.  30. 


Fig.  31. 


Urates. 


Urate  of  Sodium. 


is  quite  characteristic  of  sugar.  In  performing  this  test  for  the 
first  time,  a  difficulty  may  be  experienced  on  account  of  the 
phosphates  of  the  urine  being  precipitated  by  the  alkali  of  the 
test  solution.  These  phosphates,  however,  are  thrown  down  in 
large   flakes,   which  are   seen  floating   in  a  clear  bluish-greeu 

1  London  Lancet,  Sept.  24,  1870.  Painfs  solution  consists  of  320  grains  of  sulphate  of 
copper,  neutral  tartrate  of  potassium  640  grains,  caustic  potassa  1286  grains,  distilled 
■water  20  fluidounces.  This  gives  an  opaque  yellow  color  with  diabetic  urine.  Fehling's 
liquid,  without  glycerin,  consists  of  94.73  grains  of  sulphate  of  copper,  378.91  grains 
neutral  tartrate  of  potassium,  solution  of  caustic  soda  (spec.  grav.  1.12)  3}^  fluidounces, 
and  enough  water  to  make  in  all  6  fluidounces. 


86 


S  E  M  E I O  L  O  G  Y . 


medium,  by  holding  the  tube  between  the  eye  and  the  light. 
The  presence  of  sugar  does  away  with  all  transparency,  which 
gives  place  to  a  milky  greenish  or  yellowish  opacity.  This  mode 
of  applying  the  copper  test  is  based  upon  the  fact  that  urine 
which  is  free  from  sugar  never  discharges  the  color  from  more 
than  an  equal  bulk  of  Fehling's  solution.  Fehling's  solution  is 
apt  to  deteriorate  by  keeping,  so  that  without  any  addition  it 
may  cause  a  precipitation  of  cuprous  oxide  upon  boiling.  Pro- 
ceeding, however,  in  the  manner  described,  the  test  solution  is 
boiled  first,  and  if  it  remains  clear  there  is  a  proof  that  it  is  in 
good  condition.  If,  instead,  it  forms  a  deposit  on  boiling,  it  must 
be  rejected  and  a  fresh  supply  of  it  made." 

Maumene''s:  Dip  into  the  liquid  a  strip  of  flannel  (not  linen  ox 
muslin)  saturated  with  a  solution  of  bichloride  of  tin  in  twice  its 
weight  of  water.  The  strip,  on  being  heated  over  a  fire  or  lamp 
to  near  300^^  Fahr.,  will  at  once  become  brownish-black,  like 
caramel. 

Bottger^s :  Add  a  few  drops  of  dilute  solution  of  nitrate  of  bis- 
muth in  nitric  acid  ;  make  the  liquid  alkaline  with  carbonate  of 
sodium,  and  boil  for  a  few  minutes.  When  sugar  is  present, 
it  becomes  dark,  and  will  gradually  throw  down  a  grayish-black 
deposit.     If  the  urine  were  healthy,  a  white  deposit  would  fall. 


Fig.  32. 


Fig.  33. 


Urate  of  Sodium. 


Urate  of  Ammonium. 


Fermentation^  on  the  addition  of  yeast,  at  80°  Fahr.,  will  only 
occur  in  saccharine,  not  in  ordinary  urine.  During  this  process, 
the  white  scum  which  forms  is  found,  under  the  microscope,  to 
contain  the  chains  of  oval  vesicles  of  torula  (saccharomyces)  which 
characterize  vinous  fermentation. 

TrommeT''s  test  is  the  one  most  generally  employed.  Occa- 
sionally a  substance  called  aTka'pton  may  be  present,  which  like- 
wise reduces  the  oxide  of  copper  ;  but  it  will  not  ferment,  nor 
cause  a  dark  deposit  with  bismuth.  Its  possible  existence  does 
not  interfere  with  the  practical  value  of  this  test  for  sugar. 

Beale  mentions  that  chloroform  will,  like  grape  sugar,  reduce 
the  suboxide  of  copper.     Dr.  J.  B.  Eoberts^  has  observed  that 


1  Amer.  Journal  of  Med.  Sciences,  October,  1877,  p.  424. 


SYMPTOMS URINATION. 


87 


the  copper  test  will  llirow  down  a  yt^llowish  deposit  in  the  urine 
of  patients  taking  cliloral  as  a  medicine. 

Coloriiigf  matters  taken  as  medicine  or  food  may  sometimes 
occur  in  tlie  urine  ;  as  rhubarb,  senna,  logwood,  ccjfl'ee,  etc. 
Santonin  gives  a  light  yellow  color  to  the  urine.  Mineral  acids 
will  change  the  color  of  rhubarb  or  senna  to  a  bright  yellow. 
Aqua  ammonite  will  turn  the  orange  liue  of  rhubarb  to  crimson. 

The  following  passages'  contain  much  information  in  regard 
to  the  meaning  of  urinary  changes  in  disease  : 

"The  quantity  of  urine  is  increased  in  hysteria,  neuralgia,  the 
beginning  of  fevers,  diabetes,  the  begiiuiing  of  cirrhosis  of  the 
liver,  and  of  hypertrophy  of  the  heart ;  diminished  in  the  hot 
stage  of  fevers,  more  advanced  cirrhosis  of  the  liver,  and  hyper- 
trophy of  the  heart.  An  increase  in  quantity  after  diminution 
is  favorable,  as  it  shows  that  the  disease  has  reached  its  acme. 

"  The  density  of  the  urine  is  reduced  in  different  nervous 
afiections,  in  granular  degeneration  of  the  kidneys,  the  cold 
stage  of  fevers,  and  in  many  instances  of  that  period  of  collapse 
which  ushers  in  local  inflammation.  The  tendency  in  all  diseases, 
and  especially  in  inflammations,  as  they  approach  termination, 
is  to  give  rise  to  an  increase  of  the  specific  gravity  of  the  urine, 
except  in  granular  degeneration  of  the  kidney,  the  influence  of 
which  is,  from  first  to  last,  to  lower  the  specific  gravity  of  that 
secretion.     In  phthisis,  fluctuations  are  observed,  and  we  are 


Fig. 34. 


Fig.  35. 


Triple  Phosphate. 


Cystine. 


frequently  able  to  draw  important  inferences  from  them  ;  thus  a 
high  specific  gravity,  with  only  slight  diurnal  fluctuations,  indi- 
cates an  acute  form  of  the  disease  ;  a  lower  specific  gravity,  with 
a  greater  daily  range,  a  chronic  form  ;  while  a  density  nearly 
normal  occurs  in  cases  in  which  the  disease  is  stationary.  In 
cancer  of  the  stomach  or  liver,  and  in  hypertrophy,  cirrhosis, 
and  abscess  of  the  liver,  the  density  is  increased  ;  and  this  is 
also  the  case  in  any  disease  involving  a  mechanical  obstruction 
to  the  flow  of  bile. 

1  Black,  in  St.  Andrew's  Med.  Graduates'  Association  Reports,  1870;  condeDsed  by 
J.  H,  H.,  in  Am,  Journal  of  Med.  Sciences,  Jan.,  1871. 


SEMEIOLOGY. 


"  The  color  of  the  urine  is  made  pale  by  nervous  diseases,  by- 
diabetes,  by  granular  degeneration  of  the  kidney,  and  by  the 
phosphatic  diathesis.  It  is  milky  whenever  it  contains  pus  or 
chyle.  In  oxaluria,  in  active  inflammation,  in  fevers,  it  is  of  a 
yellowish  or  brownish -red  color. 

"The  occurrence  of  the  urates,  as  a  deposit  in  the  urine,  indi- 
cates either  an  excess  of  food,  or  of  disintegration  of  the  tissues. 
In  an  acute  disease  a  deposit  of  urates  is  generally  indicative  of 
a  tendency  to  recovery,  but  in  wasting  diseases,  as  phthisis,  their 
amount  is  simply  a  measure  of  disintegration.  They  occur  dur- 
ing convalescence  from  inflammation,  and  depend  probably  on 
the  absorption  of  the  exudation,  and  hence  will  be  deposited  for 
a  longer  time  after  inflammation  of  a  serous  than  of  a  mucous 
membrane,  because  in  the  former  case  there  is  no  direct  outlet 
for  the  exudation  as  in  the  latter.  If,  after  the  eruptive  fevers 
have  attained  their  height,  no  urates  are  observed  in  the  urine, 
complications  or  sequelae  are  to  be  feared  ;  or  if  in  acute  gout  or 
rheumatism  the  improvement  of  a  joint  is  suddenly  followed  by 
the  disappearance  of  the  sediment  from  the  urine,  another  joint 
will  soon  be  involved.  The  urates  will  be  reddish  in  color  in 
inflammatory  diseases,  and  in  functional  disturbances  of  the 
digestive  organs ;  pinkish  in  acute  articular  rheumatism,  but 
whitish  whenever  there  exists  nervous  irritation  rather  than 
inflammation." 

Fig.  3^. 


Vaginal  Epithelium  in  Urine. 

The  quantitative  analysis  of  urine,  to  determine  the  amount 
and  proportion  of  its  different  ingredients,  requires  considerable 
chemical  proficiency. 


850  to  1020  g; 

rains. 

463  to  617 

7.5 

4.5 

7.0 

7.5 

154  to  200 

23  to   38 

56 

•  19 

10 

SYMPTOMS  —  URINATION.  89 

Tho  foUowinfij  statcmont  of  the  normal  average  amount  of  the 
constituents  of  healthy  urine,  passed  in  twenty-four  hours,  is 
from  Thudichuin  : 

Solids  altogether   . 

Urea 

Uric  acid        .        .        /       . 
Creatin  .... 

Creatinin        .... 
Hippuric  acid 
Chloride  of  Sodium 
Sulphuric  acid 
Phosphoric  acid     . 
Earthy  phosphates 
Ammonia       .... 

Besides  sarkin,  iira?maiin^  uroxanthin.,  potassa,  soda^  lime,  mag- 
nesia, iron,  trimethylamine,  carbonic  acid,  xjhenylic  acid,  and 
damaluric  acid  in  undetermined  amounts.^ 

As  the  specilic  gravity  of  the  urine  varies  in  health  from  1015 
to  1025,  and  in  disease  from  1005  to  1070,  an  approximative  esti- 
mate of  the  amount  of  solids  may  be  obtained  by  doubling  the  last 
two  figures  of  the  S2)ecific  gravity.  Thus,  urine  having  a  specilic 
gravity  of  1030  will  contain  about  60  grains  of  solids  per  ounce.'' 

Heavy  and  dark-colored  urine  {diabetic  urine  is  straw  or  am- 
ber colored),  with  a  strong  odor,  may  be  inferred  to  contain  an 
excess  of  solids  from  waste  of  tissue  ;  among  which  urea  is  the 
most  important. 

Prolonged  muscular  exercise  and  highly  nitrogenous  diet  both 
promote  increase  of  urea  in  the  urine.  It  would  therefore  seem 
reasonable,  when  urcemia  is  feared,  as  in  Bright's  disease,  to 
restrict  the  amount  of  animal  food  as  far  as  the  strength  of  the 
patient  will  permit. 

When  excess  of  urea  is  present,  the  addition  of  a  few  drops  of 
strong  colorless  nitric  acid  to  the  urine  on  a  watch-glass  will 
throw  down  a  number  of  crystals  of  nitrate  of  urea  (delicate, 
rhomboidal,  like  those  of  saltpetre).     (See  Pig.  29.) 

For  determining  the  amount  of  urea.  Bowman  gives  the  follow- 
ing directions  :  "A  measuring-tube,  twelve  or  fourteen  inches 
long,  is  provided,  easily  closed  by  the  thumb,  and  graduated  to 
tenths  and  hundredths  of  a  cubic  inch.  This  tube  is  filled  rather 
more  than  one-third  full  of  mercury,  and  a  measured  quantity 
(50  to  60  grains)  of  urine  poured  into  it.  The  tube  is  then  quickly 
filled  to  Uie  brim  with  solution  of  hypochlorite  of  soda,  closed 
by  the  thumb,  and  inverted  under  a  saturated  solution  of  com- 
mon salt  (which  being  heavier  than  the  solution  in  the  tube,  pre- 
vents its  escape),  contained  in  a  small  mortar.  The  tube  is 
allowed  to  stand  for  three  or  four  hours,  or  until  the  volume  of 

1  StMeler  is  reported  to  have  shown  that  carbolic  acid  (carbol  or  phenol)  is  a  constant 
ingredient  of  the  urine,  to  the  extent  of  about  54  of  a  grain  daily  in  health.  Salkow- 
ski  and  Briegel  have  found  it  to  be  greatly  increased  in  some  cases  of  disease,  especially 
in  peritonitis.  See  Med.  Times  aiul  Gazette,  Oct.  12,  1878,  from  Ceniralblati  f.  d.  Med. 
Wiss.,  Nos.  30,  31,  34,  1878. 

-  Prof.  A.  Flint,  .Tr.,  asserts  that,  between  1010  and  1030,  the  laM  two  figures  of  the  spe- 
cific gravity  indicate,  very  nearly,  the  number  oi  grains  ofsolids  per  ounce. 


90 


SEMEIOLOGY, 


the  nitrogen  ceases  to  increase,  and  the  amount  of  urea  is  calcu- 
lated (1.549  cubic  inches  of  nitrogen  gas  representing  1  gr,  of 
urea).  In  this  process  the  carbonic  acid  is  retained  by  the  excess 
of  chlorite  of  soda  employed.  To  prepare  this  solution  of  hypo- 
chlorite of  soda,  500  grains  of  good  chloride  of  lime  (bleaching 
powder)  are  stirred  with  boiling  water,  filtered,  and  the  residue 

Fig.  37. 


Epithelial  Cells  from  bladder,  ureter,  aud  kidney. 

washed  once  or  twice  with  the  boiling  water  ;  1000  grs.  of  crys- 
tallized carbonate  of  soda  are  dissolved  in  a  little  water,  and  added 
to  the  solution,  which  is  then  filtered  and  made  up  to  20  oz, 
with  water." 

A.  Gamgee  (1878)  prefers  sodium  hypobromite  solution  for  the 
quantitative  estimate  of  urea.  It  decomposes  urea  into  carbonic 
acid  and  nitrogen  ;  the  former  is  absorbed  by  the  alkaline  solu- 
tion, and  the  nitrogen  can  then  be  measured  as  in  the  above- 
mentioned  process. 

To  estimate  the  amount  of  sugar  in  urine,  Pavy's  solution  (see 
note  to  p.  85)  may  be  used ;  100  minims  of  it  being  decolorized 
by  half  a  grain  of  sugar. 

Excess  of  phosphates  is  generally  associated  with  disintegration 
of  brain  and  nerve-tissue.  Bence  Jones  and  others  have  found 
the  phosphates  deficient  in  the  urine  in  delirium  tremens,  and  in 
excess  in  inflammatory  affections  of  the  brain.  Dr.  Luther  H. 
Wood,  however,  in  an  elaborate  investigation,  disproves  the  sup- 
position, based  on  some  previous  observations,  that  mental 
activity  causes  a  general  increase  of  the  phosphates.  He  finds  that 
the  alkaline  phosphates  are  slightly  increased  by  mental  exertion, 


SYMPTOMS URINATION.  91 

but  the  earthy  phosphates  are  diminished.,  and  the  total  amount  of 
phosphoric  acid  in  the  urine  is  not  increased  to  any  important 
extent.' 

Chloride  of  sodium  has  been  found  (Redtenbacher)  to  disap- 
pear from  the  urine  in  the  height  of  an  attack  of  pneumonia,  and 
(Beale)  to  appear  at  the  same  time  in  excess  in  the  sputa.  This 
may  be  tested  by  the  addition  of  a  few  drops  of  nitric  acid,  fol- 
lowed by  solution  of  nitrate  of  silver— a,  white  precipitate  of  chlo- 
ride of  silver  indicating  the  presence  of  the  chloride  of  sodium.^ 

Fatty  matter  in  the  urine  is  detected  by  the  microscope,  and 
by  the  use  of  ether,  which  will  dissolve  the  oily  particles  from 
the  extract  obtained  by  evaporation. 

Kyestein  is  a  greasy  pellicle  found  on  the  surface  of  the  urine 
(after  standing  a  day  or  two)  of  pregnant  women,  or  (Kane)  in 
those  whose  mammary  glands  are  excited  by  sympathy  with 
uterine  irritation.  Urostealith  is  a  solid  adipose  concretion 
(Roberts),  now  and  then  making  part  of  a  calculus. 

In  a  low  state  of  vitality  (Inmanj  the  urine,  after  being  passed, 
undergoes  decomposition  more  rapidly  than  during  health. 

For  diagnostic  chemical  analysis  of  urine  by  the  student  or 
practitioner,  simple  apparatus  will  answer.  There  are  needed 
half  a  dozen  test-tubes,  a  urinometer,  a  spirit  lamp,  litmus  and 
turmeric  paper,  graduated  glasses  (6-ounce,  1  fl.-ounce,  and  1  fl.- 
draclim),  a  stirring  rod  and  drop  tube,  a  glass  funnel  and  filtering 
paper,  a  porcelain  evaporating  dish,  and  a  small  amount  of  each 
of  the  following  reagents  :  nitric,  nitroso-nitric,  hydrochloric, 
sulphuric,  and  acetic  acids,  liquor  potassse,  aqua  ammoniae, 
nitrate  of  silver  solution,  sulphate  of  copper  solution  (94.73 
grains  in  the  ounce),  and  sometimes  alcohol,  solution  of  chloride 
of  barium  (to  test  for  sulphuric  acid  or  sulphates),  distilled  water, 
and  ether.     A  blowpipe  may  be  added  for  use  with  calculi. 

Microscopical  examinations  may  be  made  satisfactorily  for 
ordinary  purposes  with  an  instrument  of  moderate  cost ;  such  as 
Woodward's  student's  microscope.^  (Guidance  should  be  sought 
for  in  the  works  of  Beale,  Carpenter,  Hogg,  or  Richardson,  on 
the  microscope.) 

Urinary  Calculi. 

Gravel,  formed  in  the  kidneys  and  passed,  sometimes  with  much 
pain,  along  the  ureters  to  the  bladder,  and  thence  out  through 
the  urethra,  consists  commonly  of  urates  of  ammonium  and  so- 
dium, and  uric  acid. 

Calculi,  of  larger  size,  are  in  a  majority  of  cases  composed  of 
uric  acid.  Such  are  smooth,  or  but  slightly  rough  outside,  formed 
in  concentric  layers  of  different  thickness.  They  will  dissolve  in 
a  dilute  solution  of  potassa  ;  or  in  strong  nitric  acid,  with  effer- 
vescence.    The  microscope  will  show  the  uric  acid  crystals. 

Next  in  frequency  is  the  calculus  formed  of  a  mixture  of  phos- 
phate of  calcium  with  triple  phosphate  (of  magnesium  and 

1  Silliman  Prize  Essay,  Kew  Haven,  1869 ;  and  American  Journal  of  Medical  Sciences, 
April,  1870,  p.  506. 

-  Chloride  of  ammonium  will  produce  the  same  reaction  ;  but  this  salt  is  rare  in  the 
urine  or  sputa. 

3  Made  by  J.  W.  Queen,  Philadelphia  and  New  York. 


92 


SEMEIOLOGY. 


ammonium),  caMedftmhle  calculus ;  because,  before  the  blowpipe, 
it  melts  readily  without  combustion. 
Calculus  Diphosphate  of  calcium  is  generally  smooth  and  polished 

Fig.  38. 


Fig.  39. 


Lithic  Acid  Calculus  (section). 


Mulberry  Calculus. 


on  the  outside  ;  it  chars  before  the  blowpipe.     So  does  the  rather 
rare  calculus  of  triple  phosphate  alone. 

Oxalate  of  calcium  forms  the  so-called  mulberry  calculus ; 
irregular  and  rugged  in  structure  throughout.  It  may  be  tested 
by  burning  a  small  fragment  to  a  white  ash  under  the  blowpipe, 
and  then  placing  this  ash  upon  reddened  litmus  paper,  and 
moistening  it.     It  will  turn  it  to  a  decided  blue  color. 

Cystine  is  occasionally  found  forming  the  substance  of  rather 
soft,  brownish,  or  greenish-yellow  calculi. 

Urostealith  has  been  already  mentioned. 

Of  184  stones  removed  by  Sir  H.  Thompson  by  lithotrity,  122 
were  of  uric  acid  and  urates,  16  of  a  mixed  character,  40  phos- 
phatic,  1  pure  phosphate  of  calcium,  4  oxalate  of  calcium,  and  1 
cystic  oxide. 

Gail-Stones. 

These  concretions  of  biliary  matter  are  formed  in  the  gall- 
bladder, and  frequently  cause  great  pain  in  their  passage  along 
the  cystic  and  common  biliary  ducts.  They  are  of  various  sizes, 
averaging  about  that  of  a  pea.  Cholesterin  forms  the  greater 
part  of  their  substance,  mixed  with  the  biliary  resinous  and  acid 
constituents  (cholic  and  choleic  acids,  taurin,  etc.)  and  coloring 
matter. 

From  a  solution  of  the  gall-stone  in  boiling  alcohol,  choles- 
terin will  crystallize,  on  cooling,  in  fine  scaly  crystals.  Though 
allied  to  the  fatty  bodies,  it  difters  from  them  in  not  dissolving  in 


SYMPTOMS  —  MOTOR    APPARATUS.  93 

a  solution  of  potash.  The  observations  of  Dr.  A.  Flint,  Jr.,  make 
it  probable  that  cholesterin  is  converted  normally  into  stercorin, 
in  which  form  it  is  excreted. 

Other  Secretions. 

The  milk  of  a  mother  may  be  affected  in  quality  as  well  as 
quantity  by  the  physical  or  even  mental  state  of  the  individual ; 
so  as  to  become  innutritions,  or  even  injurious  to  her  offspring. 
Violent  mental  agitation  in  a  mother  has  been  known  to  produce 
fatal  convulsions  in  an  infant  at  the  breast. 

In  the  parturient  state,  the  sudden  arrest  of  the  formation  of 
milk  in  the  mammary  gland,  with  the  cessation  of  the  uterine 
lochial  discharge,  is  alarming — threatening  child-bed  fever. 

Menstruation  is  not  a  secretion  ;  it  is  rather  a  periodical  dis- 
charge of  somewhat  altered  blood,  along  with  ovulation^  or  the 
escape  of  a  germ  from  the  ovary.  Its  occurrence,  however,  is 
necessary  to  the  health  of  the  female,  from  15  to  45  years,  about, 
and  its  variations  and  deviations  are  important  signs  of  disease. 

Abnormality  in  menstruation  is,  principally,  either  amenor- 
rhcea,  dysmenorrhoea,  or  menorrhag'ia.  The  first,  amenorrhea, 
is  either  (1)  non-appearance,  (2)  suppression,  or  (3),  retention  of 
the  menses.     The  last  of  these  (retention)  is  rare. 

Suppression  or  irregularity  of  menstruation,  apart  from  preg- 
nancy, may  result  from  uterine  or  ovarian  disease,  or  from  con- 
stitutional  conditions  affecting  tlie  uterus  or  ovaries  functionally. 
The  latter  is  the  more  common  in  general  practice.  The  amenor- 
rhceal  woman  is  generally,  though  not  alwaj'^s,  ancemic. 

Dysmenorrlioea  (painful  menstruation)  may  be  either  obstruc- 
tive, spasmodic,  or  neurotic.  The  j^rsi  may  occur  from  congenital 
smallness  of  the  orifice  of  the  neck  and  mouth  of  the  womb  ;  or 
retroversion,  anteversion,  or  obliquity  of  that  organ  ;  or  pressure 
by  a  tumor  ;  or  occlusion  of  the  os  by  inflammatory  bands  or 
adhesions  of  lymph.  The  diagnosis  of  such  affections  from  spas- 
modic or  neurotic  dysmenorrhoea  belongs  to  obstetric  surgery  or 
medicine.     So  does  the  consideration  of  retention  of  the  menses.^ 

Perspiration. — Changes  affecting  the  secretion  of  the  skin  have 
been  already  alluded  to,  in  connection  with  the  signs  of  disease 
belonging  to  the  tegument.  Strong  odor  of  the  perspiration 
indicates  vicarious  excretion  by  the  sweat-glands,  and  commonly 
accompanies  insufficient  action  of  the  bowels.  Acidity  of  the 
perspiration  is  sometimes  dependent  on  the  presence  of  an  excess 
of  uric  acid;  which,  in  gout,  in  the  form  of  urate  of  sodium,  is 
occasionally  concreted  palpably  upon  the  surface  of  the  body. 
Sudoric  acid  is  said  by  Favre  to  take  the  place  of  uric  acid,  nor- 
mally. The  perspiration  contains  also  chloride  of  sodium,  urea, 
lactic  acid,  ammonia,  etc.  The  odor  of  the  perspiration  is  peculiar 
in  small-pox,  typhus,  gout,  albuminuria,  etc. 

SYMPTOMS  CONNECTED  WITH  THE  MOTOR  APPARATUS. 

The  decubitus,  or  mode  of  lying  down,  of  a  patient,  should  be 
noticed.    Inability  to  rise  may  depend  upon  general  debility,  paraly- 


1  See  "  Unclassified  Affections,"  in  Part  II. 


94  SEMEIOLOGY, 

sis  of  the  extremities,  rheumatic  or  gouty  inflammation  of  the 
joints,  etc.,  or  injuries,  such  as  fractures  or  dislocations. 

Inability  to  lie  down  is  most  frequently  the  result  of  dyspnoea 
(orthopnoea)— the  respiratory  muscles  having  the  freest  scope  in 
the  erect  position. 

In  colic,  the  patient  generally  prefers  to  lie  upon  the  belly. 

In  peritoyiitis,  the  characteristic  position  is  upon  the  back,  with 
the  knees  draivn  up,  to  relax  the  abdominal  muscles. 

Lying  upon  one  side  is  often  significant  in  disease.  In  the  early 
stage  of  pleurisy,  the  patient  prefers  to  lie  upon  the  healthy  side ; 
when  effusion  has  taken  place,  this  is  reversed.  In  irritative  dis- 
order of  the  liver,  with  enlargement,  the  patient  will  often  lie 
most  comfortably  upon  the  right  side.  When  the  heart  is 
enlarged  or  violent  in  its  action,  the  sufferer  generally  cannot  lie 
upon  the  left  side.  The  exceptions  are  most  frequent  in  cases  of 
long  duration. 

In  aneurism  of  the  aorta,  the  prone  or  semi-prone  position  (as 
leaning  forward  over  a  chair  or  a  bed)  is  sometimes  preferred. 

Muscular  debility  may  be  the  result  of  acute  disease,  as  fever, 
or  of  actual  exhaustion  and  prostration.  Total  want  of  exercise 
will  enfeeble  the  muscles ;  as,  when  a  limb  is  long  confined  in 
splints  on  account  of  a  fracture  or  other  injury.  Inability  to 
walk  steadily  without  constant  guidance  by  sight,  is  among  the 
symptoms  of  locomotor  ataxia. 

Spasm  is  of  three  kinds  :  tonic,  clonic,  and  choreic. 
Tonic  spasm  is  fixed  rigidity ;  such  as  emprosthotonos  (arching 
of  the  body  forwards),  or  opisthotonos  (arching  backwards),  in 
tetanus.  Clonic  spasm  is  ordinary  convulsion  ;  i.  e. ,  successive  con- 
tractions of  the  muscles  at  short  intervals  Choreic  spasm  is  a 
term  suggested  to  indicate  the  jerking,  irregular  movement  of 
the  muscles,  not  controllable  by  the  will,  in  cases  of  chorea. 

Tremor  is  of  two  kinds  :  incidental  or  volitional  tremor,  occur- 
ring only  when  muscular  action  is  attempted  ;  and  habitual  or  con- 
stant  tremor,  which  takes  place  while  the  individual  is  at  rest,  as 
well  as  when  in  motion.  Multiple  cerebro-spiyial  sclerosis  is,  in 
many  cases,  attended  by  the  former ;  paralysis  agitans  exemplifies 
the  latter.  Erb,  Hammond,  and  others  assert  that  volitional 
tremor  occurs  only  when  some  part  of  the  brain  is  involved  in 
disease. 

Rigidity  is  different  from  spasm ;  although  sometimes  closely 
connected,  as  in  s-pastic  spinal  paralysis.  In  cases  of  palsy,  we 
may  meet  with  early  and  late  rigidity  (Todd)  from  different  path- 
ological causes.  The  first  is  connected  with  irritation  of  nerve- 
centres  ;  the  second,  with  degeneration. 

Subsultus  tendinum,  or  jerking  of  the  tendons  at  the  wrist,  is 
one  of  the  symptoms  of  low  states  of  continued  fever. 
Paralysis  will  be  alluded  to  presently. 

SYMPTOMS  CONNECTED  WITH  THE  SENSORY  APPARATUS. 

Of  these,  the  most  important  is  pain.    Pain  may  be — 

Acute,  sharp,  cutting,  as  in  pleurisy ; 
Shooting,  darting,  as  in  neuralgia ; 
Lancinating,  in  cancer ; 


SYMl'TOMS — SENSORY     AIM'AKATUS.  95 

Gnawing,  tearing,  in  rliouinatism  ; 
Dull,  heavy,  aching,  in  pneumonia; 
Griping,  hvisting,  in  dysentery  ; 
Bearing  down,  in  second  staj^c  of  labor  ; 
Pulsating,  in  the  Ibrmation  of  an  abscess  ; 
Burning,  .wiarling,  in  erysipelas; 
Stinging,  nettling,  in  urticaria  ; 
Constant,  or  intermittent;  fixed  or  wandering. 

Tenderness  mi  ^nessure  is  generally  associated  with  inflamma- 
tion; although  some  affections  designated  as  neuralgic  also  pre- 
sent it— possibly  from  inflammation  of  the  sheaths  of  the  nerves. 
Exhausted  inuscles  also  have  it,  with  pain  (myalgia  of  Innian). 

Sometimes  pain  is  relieved  by  pressure;  as  in  many  cases  of 
colic  and  dysmenorrhoea.  This  is  a  sign,  usually,  of  the  absence 
of  inflammation. 

Pain  is  not  always  at  the  seat  of  disease.  Thus,  in  disease  of  the 
hip-joint  (morbus  coxarius),  the  pain  is  felt  chiefly  at  the  knee ; 
in  calculus  of  the  bladder,  at  the  glans  penis;  in  ovarian  disease, 
sometimes,  along  the  limbs;  in  disorder  of  the  liver,  often,  under 
the  scapula ;  in  dyspepsia,  frequently,  about  the  sternum  ;  and  in 
irritation  of  the  uterus,  at  the  top  of  the  head. 

Total  loss  of  sensation,  local  or  general,  is  called  anaesthesia. 
Hyperaesthesia  is  excessive  sensibility.  Acinesia  (a  term  seldom 
used )  is  loss  of  muscular  power. 

Paralysis  of  one  side  only,  of  the  body,  e.  g.,  the  right  arm  and 
leg,  is  hemiplegia.  Paralysis  of  both  lower  extremities,  paraplegia. 
These  terms  are  commonly  applied  either  to  loss  of  power,  or  loss 
of  sensibility,  or  the  more  usual  combination  of  both.  The  cause 
of  paralysis  may  be  local  (lesion  of  a  nerve)  or  in  the  spinal  mar- 
row, or  in  the  brain. 

In  the  diagnosis  of  cases  of  paralysis,  the  reaction  of  the 
muscles  to  electricity  is  often  important.  When  hemiplegia 
(paralysis  on  one  side  of  the  body)  or  paraplegia  (palsy  of  the 
limbs  on  both  sides)  is  produced  by  disease  of  the  brain,  or  of  the 
spinal  cord  above  the  insertion  of  the  nerves  supplying  the 
affected  limbs,  the  muscles  of  those  limbs  will  respond  to  both 
the  "faradic"  and  the  "galvanic"  currents.  When,  however, 
the  paralysis  results  from  disease  of  the  nerves  supplying  the 
muscles,  or  that  part  of  the  spinal  cord  with  which  those  nerves 
are  directly  connected,  the  paralyzed  muscles  react  with  unusual 
susceptibility  to  the  galvanic  current,  but  owt  at  all  to  the  faradic 
current.  This  (reaction  of  degeneration,  Erb ;  better  called 
reaction  of  local  or  pjroximate  lesion)  is  observed  often  in  acute 
facial  paralysis  from  inflammation  of  the  sheath  of  the  seventh 
or  facial  nerve  on  one  side.  When  disease  or  injury  of  the  brain 
causes  paralysis  of  the  same  muscles  (other  muscles  also  being 
then  commonly  involved)  they  will  react  to  both,  the  galvanic  and 
the  faradic  currents ;  unless,  at  least,  descending  neuritis  modify 
the  case,  and  produce  a  true  reaction  of  degeneration. 

The  eye  affords  many  indications  of  disease.  A  prominent  and 
turgid  condition  of  both  eyes  occurs  in  acute  ophthalmia,  and  in 
congestion  of  the  brain ;  also  not  unfrequently  in  fevers ;  espe- 
cially yellow  fever.      The   eyeballs   are   notably    prominent   in 


96  SEMEIOLOGY. 

exophthalmic  goitre.  If  one  eye  alone  becomes  prominent,  local 
disease,  e.  ^.,  a  tumor  behind  the  orbit,  may  be  suspected.  The 
eyes  are  sunken,  in  phthisis,  and  in  other  wasting  maladies. 
Sinking  of  one  eye  indicates  local  atrophic  disease. 

The  movements  of  the  eye  should  be  noticed,  especially  in 
children.  Rolling  of  the  eyeballs  from  side  to  side  (nystagmus) 
is  a  common  symptom  of  nervous  restlessness  or  cerebral  irrita- 
tion in  infants.  Squinting^  occurring  as  a  symptom  in  disease,  is 
of  unfiivorable  import.  Sometimes,  however,  seeing  double  occurs 
transiently,  under  sympathy  of  the  brain  with  gastric  irritation. 

The  color  of  the  eyes  varies  in  disease.  In  conjunctivitis^  the 
blood-vessels  are  generally  enlarged,  and  the  membrane  reddened. 
In  sclerotitis^  the  enlarged  vessels  are  seen  converging  toward  the 
margin  of  the  cornea.  In  iritis^  discoloration,  irregularity,  and 
sometimes  fixedness  of  the  pupil  occur.  ^ 

The  cornea  in  old  people  occasionally  exhibits  the  arcus  senilis 
— a  sign  of  fatty  degeneration.  It  is  an  opacity  around  the  cir- 
cumference of  the  cornea. 

The  lustre  of  the  eye  is  lessened  generally  in  depressing  acute 
diseases,  and  especially  just  before  death. 

The  eyes  are  often  remarkably  bright  during  the  progress  of 
phthisis.  They  have  a  glare  in  some  cases  of  inflammation  of 
the  brain  and  of  mania. 

The  pupil  is  generally  contracted  in — 
Inflammation  of  the  retina  ; 
Inflammation  of  the  brain  ; 
Apoplexy  of  the  pons  Varolii ; 

Narcotism  by  opium,  chloral,^  pilocarpin,'  or  the  Calabar 
bean. 

It  is  dilated,  usually,  in — 

Apoplexy  ;  Amaurosis ; 

Hydrocephalus  ;  Cataract ; 

Narcotism  by  belladonna,  stramonium,  duboisia,  or  prussic 
acid. 

An  immovable  state  of  the  pupil,  or  a  difference  between  the  two 
eyes  under  the  same  light,  gives  rise  to  suspicion  of  ophthalmic  or 
cerebral  disorder. 

Photophobia  is  a  dread  of  or  shrinking  from  the  light,  such  as 
occurs  in  ophthalmia,  and  in  meningitis  or  cerebritis.  Other 
symptoms  connected  with  the  eye  are — 

Photopsia,  flashes  of  light  passing  before  the  eyes. 

Huscce  volitantes,  moving  spots,  or  spectra. 

Amblyopia,  dimness  of  vision. 

Di^jlopia,  double  vision. 

Hemiopia,  half-sight ;  «.  e.,  seeing  but  one-half  of  an  object  at 
a  time. 

Tinnitus  aurium,  or  ringing  in  the  ears,  may  attend  congestion 

1  Ophthalmoscopic  examination  of  the  interior  of  the  eye  is  found  to  be  useful  in  the 
diagnosis  not  only  of  diseases  of  the  eye,  but  in  those  of  the  brain. 

2  Erlenraayer,  McKendrick,  Sedgwick,  etc.  In  dogs,  Feltz  and  Bitter  have  found  the 
pupils  dilated  after  poisonous  doses  of  chloral. 

3  Laborde  and  Fitzgerald  ;  Lancet,  Nov.  13,  1880. 


SYMPTOMS PSYCHICAL    CONDITION.  97 

of  the  brain;  vervous  dehility ;  qxdninization ;  ov  disease  in  the  ear. 
Sometimes  tinnitus  results  merely  from  rhythmical  twitching  of  the 
tensor  tympani  muscle.  Leafiiess  niay  proceed  from  coryza  (a  cold 
in  the  head);  icax  in  the  ears  ;  quininization ;  typhus  or  typhoid 
fever  ;  disease  of  the  ear ;  cerebral  disease. 

Pain  in  the  head  (cephalalgia)  may  be  especially  alluded  to  as 
depending  upon — 

Neuralgia  ; 

Rheumatism  of  the  scalp  ; 

Congestion  of  the  brain  ; 

Ura3mia ; 

Toxsemia  (e.  y.,  by  narcotics,  alcohol,  etc.); 

Fever  (remittent,  yellow,  typhoid,  etc.); 

Chronic  disease  of  the  brain  ; 

Uterine  irritation,  etc. 
The  distinction  between  these  different  forms  of  headache  is  by 
no  means  always  easily  made  out.  As  a  general  statement,  it 
may  be  said  that  neuralgic  headache  is  mostly  on  one  side  (hemi- 
crania),  and  extends  more  or  less  to  the /ace;  it  is  usually  accom- 
panied, also,  by  sensitiveness  of  the  scalp,  and  is  shooting  or  darting 
in  its  character.  Rheumatism  of  the  head  is  attended  by  stiffness 
of  the  muscles  which  move  the  head  from  side  to  side.  Congestive, 
febrile^  and  toxcemic  headaches  are  accompanied  by  heat  of  the 
head,  and  are  throbbing  or  pulsating.  That  o^  uterine  irritation  is 
on  the  top  of  the  head.  That  of  urmmia  is  more  often  occipital. 
The  pain  of  chronic  cerebral  disease  (tumors,  etc.)  is  commonly 
constant  or  periodic  in  one  spot,  and  is  attended  by  some  functional 
disorder  of  the  brain. 

SYMPTOMS  CONNECTED  WITH  THE  PSYCHICAL  APPARATUS. 

The  expression  of  the  countenance  is  usually  altered  by  disease, 
especially  of  an  acute  kind.  The  change  from  anxiety  or  distress 
to  serenity  is  always  a  favorable  prognostic,  except  where  gangrene 
or  paralytic  ancesthesia  accounts  for  it. 

Great  anxiety  of  expression  is  seen  especially  in  organic  disease 
of  the  heart,  and  in  acute  disorders  of  the  abdominal  viscera.  In 
hypochondriasis,  a  sad  and  desponding  expression  prevails. 

Terror  is  shown  by  the  countenance  in  delirium  tremens. 

Rage,  in  some  cases  of  hydrophobia,  and  sometimes  in  acute 
mania. 

Insanity  and  imbecility,  although  not  characterized  by  any  spe- 
cial cast  of  countenance,  yet  modify  its  expression  so  as  to  enable 
the  mental  state  to  be  detected  by  one  accustomed  to  the  obser- 
vation of  deranged  persons. 

The  fades  Hippocratica  is  the  countenance  of  extreme  exhaus- 
tion or  of  the  moribund  state  ;  so  called  because  of  its  having  been 
well  described  by  Hippocrates,  the  father  of  Medicine. 

Delirium  is  described  as  being  either  active  or  passive.  Active 
delirium  is  present  in  cases  of  acute  meningitis  ;  passive  or  low 
muttering  delirium,  in  typhus  fever,  etc. 

Coma  presents  itself  in  practice  chiefly  in  five  forms  :  Alcoholic 
stupefaction  ;  Opium  poisoning  ;  Apoplexy  ;  Typhus  ;  Fracture 
of  the  skull  with  compression  of  the  brain. 
9  G 


98  SEMEIOLOGY. 

Typhous  stupor  is  generally  easy  of  recognition ;  the  others  may 
give  some  trouble  in  the  diagnosis.  Between  narcotism  by  opium 
and  dead-drunkenness  we  have  the  distinctions,  that  in  opiate 
poisoning  the  pupil  is  almost  always j^rm??y  contracted^  and  that  the 
breath  smells  of  alcohol  (or  aldehyde)  in  the  intoxicated  subject. 

Loss  of  speeeh,  without  affection  of  the  vocal  apparatus,  con- 
stitutes the  disorder  called  aphasia.  Aphonia  is  loss  of  voice  from 
a  morbid  condition  of  the  vocal  chords  or  muscles  of  the  larynx. 

Vertigo,  or  dizziness,  is  mostly  symptomatic  of  disorder  of  the 
stomach,  or  of  the  liver  (cholseniia) ;  sometimes,  of  general  debil- 
ity ;  rarely,  of  disease  of  the  brain. 

GENBRAIi  VITAL  CONDITION". 

Lyons  (Hospital  Practice)  remarks  as  follows  :  "  The  highest 
skill  in  physical  diagnosis,  and  the  most  profound  knowledge  of 
pathological  anatomy,  will  leave  you  but  very  imperfect  and 
unsafe  practitioners,  incapable  of  clear  judgment  and  self-reliance 
in  difficult  cases  in  which  you  have  to  rest  on  your  own  responsi- 
bihty,  if  you  do  not  from  the  first  endeavor  to  master  and  acquire 
for  yourselves  that  unwritten  and  indescribable  knowledge  which 
constitutes  the  consummate  skill  of  the  experienced  medical  man. 
It  consists  in  a  faculty  of  appreciating  the  vital  state  of  your 
patient ;  of  forming  a  rapid  but  complete  and  accurate  estimate 
of  the  nervous  and  muscular  force  which  he  possesses  ;  or,  in 
general  terms,  of  the  powers  of  life  which  remain  to  him — his 
viability,  so  to  speak,  or  the  power  which  his  system  retains  of 
resisting  the  morbid  or  fatal  influences  of  injury  or  disease." 

PHYSICAL  DIAGNOSIS. 

The  idea  of  physical  exploration  for  the  purpose  of  diagnosis 
has  been  well  defined  by  Piorry,  in  the  word  "  Organography :" 
i.  e.,  the  determination  of  the  actual  and  relative  position,  mate- 
rial condition,  and  functional  action  of  the  organs  contained  within 
the  body.  The  methods  in  use  for  this  purpose  are  modern, 
dating  from  Auenbrugger,  of  Vienna,  the  inventor  of  diagnostic 
percussion,  in  1761,  and  Laennec,  the  great  originator  of  auscul- 
tation, about  ^  1818. 

The  modes  of  examination  of  the  chest,  abdomen,  etc.,  are — 

Inspection ;  Mensuration ;  Palpation ;  Succussion ;  Spirometry ; 
Percussion ;  Auscultation. 

By  inspection,  we  estimate,  with  the  eye,  the  form,  size,  and 
movements  of  the  chest,  etc. 

By  mensuration,  we  obtain  a  more  accurate  knowledge,  espe- 
cially of  deviations  and  alterations  of  size  and  form. 

Palpation  aids  in  the  determination  of  the  character  of  surfaces 
and  of  subjacent  parts,  and,  in  the  chest,  detects  changes  in  the 
degree  or  extent  of  the  movements  of  respiration  and  of  the  heart, 
and  in  the  vibrations  connected  with  the  voice,  cough,  and  breathing. 

Snccussion,  or  shaking  the  chest  suddenly,  is  of  use  occasionally, 
in  establishing  the  presence  of  fluid  in  the  thoracic  cavities. 

Spirometry  is  the  measurement  of  the  capacity  of  the  lungs 
for  air. 

1  The  idea  of  auscultation,  however,  was  known  even  to  Hippocrates. 


MENSURATION    AND    PALPATION.  99 

By  percussion  we  learn  mueh  of  the  physical  condition  of  the 
lungs,  heart,  and  abdominal  viscera,  through  the  variations  of 
resonance  and  resistance  when  the  walls  of  the  thorax  or  abdomen 
are  lightly  struck. 

Auscultation  is  equally  important,  but  somewhat  more  difficult 
in  its  application,  on  accdunt  of  the  complexity  of  the  signs 
afforded  by  it.  It  consists  in  directly  listening  to  the  sounds 
produced  within  the  cavities  of  the  body,  by  placing  the  ear,  with 
or  without  the  stethoscope,  upon  the  surfaces  thereof. 

The  Regions  of  the  Chest,  for  the  purpose  of  physical  explora- 
tion, may  be  most  conveniently  divided  into  the  following : — 

Anterior.  Posterior. 

Upper  and  lower  sternal ;  Interscapular ; 

Kight  and  left  clavicular ;  Dorsal ; 

Right  and  left  subclavian ;  Right  and  left  acromial ; 

Right  and  left  mammary  ;  Right  and  left  scapular ; 

Right  and  left  infra-mammary.  Right  and  left  infra-scapular. 

Lateral. 

Right  and  left  axillary ; 
Right  and  left  lateral ; 
Right  and  left  lower  lateral. 

The  most  important  peculiarities  of  these  different  regions,  in 
the  normal  state,  are  connected  with  percussion-resonance.  The 
clearest  and  fullest  sound  on  percussion  is  given  over  the  subcla- 
vian and  lateral  regions ;  the  dullest  and  smallest,  over  the  acro- 
mial, the  right  infra-mammary  (hepatic),  and  the  left  mammary  or 
prsecordial  region. 

MENSURATION  AND  PALPATION. 

For  mensuration,  various  stethometers  or  chest-measurers  have 
been  devised  ;  but,  with  care  and  judgment,  the  common  tape- 
measure  will  suffice. 

The  dimensions  to  be  compared  are  the — 

Circular :  around  the  chest  opposite  the  base  of  the  ensiform 
cartilage.  This  averages  thirty -three  inches.  The  right  half  of 
the  thorax  is  nearly  always  half  an  inch  to  an  inch  larger  in  cir- 
cumference than  the  left. 

Transverse :  from  the  nipple  to  the  middle  of  the  sternum. 

Vertical :  from  the  clavicle  to  the  lower  margin  of  the  ribs. 

Antero-posterior :  from  the  clavicle  anteriorly  to  a  correspond- 
ing point  in  the  scapular  region. 

General  expansion  and  local  bulging  of  the  chest,  and  general 
retraction  and  local  depression,  are  the  signs  most  frequently 
determined  by  inspection  and  mensuration. 

General  expansion  or  local  bulging  of  the  chest,  usually  upon 
one  side  only,  may  be  caused  by — 
Pleuritic  effusion  ; 
Pneumothorax  ; 
Emphysema  of  the  lung ; 
Aneurism,  cancer,  etc. ;  or  more  rarely,  by — 


100  SEMEIOLOGY. 

Hydrothorax ; 

Pneumonia ; 

Incipient  tuberculization.^ 

Retraction  or  local  depression  of  the  thoracic  walls  may  result 
from — 

Absorption  of  pleuretic  effusion  ; 

Tuberculization  ; 

Pneumonia  ;  cirrhosis  of  lung ; 
Pleuro-pneumonia ; 
Infiltrated  cancer  of  the  lung. 

By  palpation,  we  observe  diminution  of  the  expansion  and 
elevation  of  the  ribs  in  breathing,  in — 

Pleurisy;  Emphysema; 

Pneumonia;  Intercostal  rheumatism; 

Tuberculization  ;  Paralysis ; 

Pneumothorax ;  Hydrothorax. 

Increased  expansion  and  elevation  of  the  ribs  in  breathing 
occurs  in — 

Asthma  ; 

Group ; 

Spasm  of  the  glottis; 

Foreign  bodies  in  air-passages. 

Increased  vibration  of  the  walls  of  the  chest  with  the  voice  and 
cough  is  noticed  in — 

Tuberculization;  Pulmonary  apoplexy ; 

Pneumonia  ;  Dilatation  of  bronchi. 

Diminished  vocal  and  tussive  vibration  occurs  in — 

Pleuritic  effusion ;  Emphysema ; 

Pneumothorax ;  Cancer  of  the  lung. 

Rhonchal  vibration,  occasionally,  in  bronchitis. 
Rubbing,  or  to-and-fro  vibration,  in— 

Pleurisy ;  Pericarditis. 

Pulsatile  vibration  in — 

Aneurism  of  aorta  ; 

Cancer  of  lung  or  pleura  ; 

Pneumonia. 
Fluctuation  in— 

Large  pleuritic  effusion. 
Purring  vibration  (fremissement  eataire)  in — 

Aneurism  of  aorta; 

Valvular  heart  disease  ; 

Exophthalmic  goitre  ; 

Ansemia. 

SPIROMETRY. 

Por  Spirometry,  Hutchinson's,  Pereira's,  Coxeter's,  and  Mitch- 
ell's^ spirometers  have  been  used. 

1 A  case  is  on  record  in  which  bulging  above  the  clavicle  occurred,  from  the  pro- 
trusion of  a  lung,  in  consequence  of  tight  lacing. 
2  Consisting  of  a  small  gas-meter,  with  a  mouth-piece. 


PERCUSSION. 


101 


Hutchinson  made  elaborate  investigations  into  the  comparative 
breathing-power  of  individuals,  l^ywhich  he  proposed  to  conclude 
upon  their  vital  capacity.  A  man  5  feet  8  inches  in  height,  and 
of  155  pounds  weight,  was  found,  on  the  average,  to  expire,  after 
a  full  inspiration,  230  cubic  inches. 

For  every  inch  of  height  above  this,  a  definite  increase  in  the 
quantity  breathed  was  observed.  The  proportion  was  less  con- 
stant with  weight  and  with  age.  After  fifty-five  there  was  a 
decrease. 

In  the  first  stage  of  consumption,  the  average  (for  the  adult  of 
ordinary  height)  was  found  to  be  154  cubic  inches  ;  second  stage, 
131  ;  late  stage,  108,  etc. 

In  practice,  however,  spirometry  is  not  extensively  used.  It  is 
of  service  in  examinations  for  life  assurance. 

PERCUSSION. 

Percussion  is  either  mediate  or  immediate.  In  immediate  per- 
cussion, we  tap  with  the  ends  of  the  fingers  at  once  upon  the 
body  ;  in  mediate  percussion,  a  pleximeter  (stroke-measurer)  is 
used.  The  latter  is  almost  universal ;  but  a  difference  exists  as 
to  the  kind  of  pleximeter  employed.  Louis  and  Walshe  have  pre- 
ferred one  made  of  caoutchouc  ;  Piorry  and  Skoda,  one  of  ivory  ; 
Wunderlich,  an  ivory  disk,  upon  which  to  strike  with  a  small  steel 
hammer,  the  head  of  which  is 
covered  with  caoutchouc.  Fig.  40. 

A  majority  of  practitioners, 
however,  are  satisfied  (with  good 
reason)  with  the  use  of  the  mid- 
dle finger  of  the  left  hand  as  a  plex- 
imeter. (Percuss  by  movement 
of  the  hand  on  the  wrist;  not  by 
a  sledge-hammer  motion  from 
the  shoulder.) 

In  using  percussion  as  a  means 
of  physical  diagnosis,  we  note— 

1.  The  clearness  or  dulness  of 
the  resonance  produced. 

2.  The  duration  of  the  reso- 
nance. 

3.  Its  special  character. 

4.  The  degree  of  resistance 
felt. 

Certain  terms  are  in  common 
use  to  describe  particular  char- 
acters of  resonance  ;  as,  wooden 
sound,  thigh  sound,  stomach 
sound,  tympanitic  or  drum-like 
resonance,  amphoric  or  pitcher- 
sound,  hruit  de  pot  file  or  cracked- 
pot  sound,  etc. 

It   is    indispensable,   in   com- 
mencing the  study  of  percussion  (or  other  modes  of  physical  diag- 
nosis), to  become  familiar  with  the  normal  and  natural  sounds 
9* 


Area  of  Hepatic  dulness,  viewed 
anteriorly,  a.  b.  Right  Mammary 
line.  c.  d.  Median  line.  e.  Splenic 
dulness.  /.  Cardiac  dulness.  (Mur- 
chison.) 


102  SEMEIOLOGY. 

observed  in  health.  To  be  anything  more  than  a  routine  diag- 
nostician, moreover,  it  is  necessary  to  understand  the  principle 
of  the  exploration,  and  as  far  as  possible,  the  reason  of  the  mean- 
ing of  every  sign. 

Two  or  three  very  simple  facts  explain  the  use  of  percussion 
in  diagnosis. 

When  any  solid  body  is  struck,  the  sound  elicited  varies 
according  to  its  material,  form,  size,  and,  if  hollow,  the  condition 
of  its  walls,  and  that  of  its  contents. 

The  human  thorax  (or  abdomen)  having  a  certain  general 
form,  size,  condition  of  its  walls,  and  proportion  of  air,  blood, 
and  solid  structure  in  its  contents,  will  give  forth  a  certain 
degree  and  kind  of  resonance. 

Whatever  alters  either  the  state  of  the  walls  or  the  proportion  of 
air,  fluid,  and  solid  contained  within  them,  gives  rise  to  an  altera- 
tion of  percussion-resonance. 

Alteration  of  the  state  of  the  ivalls  of  the  thorax  seldom  occurs 
in  disease  in  such  a  way  as  greatly  to  modify  percussion-resonance. 
Changes  in  the  proportion  of  solid,  liqiiid,  and  air,  in  the  lungs 
and  pleural  cavities,  as  well  as  in  the  similar  relations  of  the 
heart  and  pericardium,  aorta,  etc.,  are  frequent.  The  more  air, 
and  the  less  liquid  or  solid  contained  within  the  part  of  the  chest 
which  is  percussed,  the  clearer  and  fuller  the  resonance,  and, 
as  a  general  rule,  the  less  the  resistance  to  the  finger.  Any 
increase  in  the  relative  proportion  of  liquid  (as  in  pleuritic  effusion), 
or  of  solid  (as  in  tuberculization),  must  cause  a  duller  or  lesser 
degree  of  resonance,  and,  other  things  being  equal,  a  greater 
degree  of  resistance. 

Thus,  local  diminutioii  of  clearness  and  duration  of  the  per- 
cussion-sound, with  increased  resistance  of  a  portion  of  the 
walls  of  the  chest,  occurs  in — 

Pneumonia;  Pulmonary  apoplexy ; 

Pleurisy  ;  Hydrothorax ; 

Tuberculization;  Cancer,  etc. 

The  extent  over  which  dulness  on  percussion  is  observed  some- 
times varies  with  the  position  of  the  patient.  This  is  practically 
important  in  the  diagnosis  of  pileuritic  effusion,  empyema,  hydro- 
thorax,  and  hydropneumothorax. 

Increased  clearness  and  duration  of  resonance,  with  decrease 
of  resistance  occurs  in — 

Pneumothorax;  Emphysema; 

Atrophy  of  lung ;  Anaemia ; 

Hypertrophy  of  lung ;  Emaciation. 

Increased  clearness  of  sound  with  increase  of  resistance  is 
observed  when  there  is  a  tubercular  cavity  near  the  surface  of  the 
chest,  with  its  outer  wall  thin,  hard,  and  adherent  to  the  pleura. 
Tympanitic  resonance  of  the  chest  is  present  in — 
Pneumothorax  ; 
Emphysema ; 
Pulmonary  atrophy,  etc. 
Amphoric  resonance,  when  there  is  a  large  tubercular  cavity^ 
with  solid  and  tense  walls  near  the  surface  of  the  chest. 


AUSCULTATION.  103 

The  cracked-pot  sound  indicates  an  anfractuous  cavity,  i.  e., 
one  whose  walls  are  broken  or  incomplete,  communicating  with 
the  bronchial  tubes.  It  may  ])e  imitated  by  clasping  the  hands 
loosely  and  then  striking  the  back  of  one  of  them  upon  the  knee. 
Skocla\'i  classification  of  percussion-sounds  has  the  merit  of 
great  simplicity.     He  distinguishes  them  as — 

Full ;  empty  {large  and  small  resonance) ; 

Clear ;  dull ; 

Tympanitic ;  non-tympanitic ; 

High ;  low  (pitch). 

A  sound  may  be  at  the  same  time  full  and  dull,  or  clear  and 
empty  (small). 

Skoda  does  not  value  very  highly  the  information  obtained  from 
differences  in  the  pitch  of  percussion-sounds.  Other  authorities 
(as  Flint)  differ  from  him,  however,  upon  this  point ;  and  with 
good  reason. 

Dr.  Da  Costa^  has  investigated,  under  the  designation  of  res- 
piratory percussion,  the  differences  made  in  percussion  reso- 
nance by  deep)  inspjiration.  In  health,  percussion  at  the  time  of 
deep  inspiration  gives  a  sound  fuller  and  of  higher  pitch  than 
during  expiration  or  in  a  medium  state  of  chest-expansion. 

In  bronchitis  (without  affection  of  the  lung),  the  same  differ- 
ence is  observed  as  in  health.  This  is  true  also  in  pulmonary 
empjhysema. 

In  acute  xmeumonia  no  difference  in  resonance  attends  deep 
inspiration. 

Pleuritic  effusion  also  prevents  the  occurrence  of  any  such  dif- 
ference over  the  seat  of  effusion. 

When,  in  phthisis,  the  dulness  on  percussion  is  no  longer  modi- 
fied by  forced  inspiration,  we  may  infer  that  the  disease  is 
advancing.  When  cavities  exist  in  the  lungs,  deep  inspiration 
will  often  increase  the  dulness  of  percussion-resonance,  and  at 
the  same  time  raise  its  pitch. 

AUSCULTATION". 

In  auscultation,  as  well  as  in  percussion  and  other  modes  of 
physical  exploration,  a  comparison  is  made  not  only  with  the 
normal  standard,  but  between  the  two  sides  of  the  chest. 

The  stethoscope  is,  in  auscultation,  generally  speaking,  a  super- 
fluous instrument.  If  any  be  used,  a  simple  wooden  tube  with 
one  end  slightly  expanded  is  the  best.  Camman's  double  stetho- 
scope'^ is  approved  by  Dr.  Flint ;  but  it  requires  a  good  deal  of 
practice  to  use  it  well.  Snelling's^  addition  of  an  India-rub- 
ber rim  is  an  improvement  to  it,  as  well  as  to  the  ordinary  steth- 
oscope. 

Upon  the  invention  of  the  microphone,  by  wliich  sounds  other- 
wise inaudible  are  made  perceptible  by  the  human  ear,  sanguine 
hopes  were  entertained  that  it  might  be  made  available  in  aus- 
cultation. Wallich*  succeeded  in  so  modifying  it  as  to  intensify  the 

1  Amer.  Journal  of  Med.  Sciences,  July,  1875. 

*  First  invented  by  Dr.  Leared,  of  London,  1851. 

3  New  York  Medical  Record,  March  15, 1870.  *  Lancet,  Nov.  30, 1878. 


104 


SEMEIOLOGY. 


Fig.  41. 


heart-sounds,  without  lessening  their  distinctness  from  each  other. 

But,  especially  on  account  of  the 
tendency  to  confusion  of  various 
sounds  together,  when  magni- 
fied by  such  an  instrument,  it 
appears  that  we  must  wait  yet 
awhile  longer  for  successful  mi- 
crophonic auscultation. 

The  beginner  must  familiarize 
himself  with  the  natural  breath- 
ing-sound, 1,  as  heard  when  the 
ear  is  placed  over  any  part  of  the 
lungs,  and  2,  with  that  heard  in 
the  sternal  and  interscapular  re- 
gions. The  latter  is  bronchial, 
the  former  is  the  vesicular  mur- 
mur. The  tubular,  blowing  char- 
acter of  the  respiration  as  heard 
in  the  bronchi,  and  its  soft,  breezy 
nature  when  the  ear  is  placed 
over  the  lungs,  are  essential  ele- 
ments in  diagnosis  by  ausculta- 
tion. 

The  pulmonary  vesicular  mur- 
mur is  always  louder  in  infants 
and  children,  ecccepi  when  they  are 
asleep  or  very  quiet.  Puerile 
respiration  is,  therefore,  the 
name  given  to  exaggerated 
breathing-sound  in  the  adult. 

In  a  healthj?^  state  of  the  lungs, 
the  expiratory  murmur  is   very 


1.  Supraclavicular.  2.  Infraclavicu 
lar.  3.  Mammary.  4.  Epigas- 
tric. 5.  Umbilical.  6.  Hypogas- 
tric.   7.  Axillary.     8.  Infra-axil- 


^lieftf;  SS-™4K„J5if,!  feto'ly  ^eari  A  prolongation, 
11.  Inguinal  (right  and  left),  ^nd  mcrease  m  loudness,  of  the 
(Paxton.)  sound  of  expiration,  is  often  a 

sign  of  disease  (tuberculization). 
The  sounds  detected  by  auscultation  of  the  chest  are  divided 

into   respiratory  and  secretory  sounds,  frictioii-sounds,  and 

modifications  of  vocal  resonance. 

Respiratory  Sounds. 

Normal  vesicular  murmur ; 
Puerile  respiration ; 
Prolonged  expiratory  sound ; 
Harsh,  tubular,  blowing; 
Bronchial,  and  cavernous ; 
Amphoric  respiration. 

Secretory  Sounds. 
Dry. 
Sibilant  rhonchus  (hissing  or  whistling) ; 
Sonorous  rhonchus ; 
Dry  crackle. 


AUSCULTATION. 


105 


Moist. 

Fine  crepitation  or  crepitant  r^le  ; 
Coai-se  crepitant  riile  (mucous  rule) ; 
Humid  crackle  or  gurgling  ; 
Metallic  tinkling  or  dropping  sound. 

Friction-sounds  are  peculiar  to  pleurisy  and  pericarditis,  at  the 

stage  of  adhesion,  or,  at  least, 

of  effusion  of  plastic  lymph.  Fig.  42, 

Modifications  o/vocal  reso- 
nance are— 

Bronchophony  ; 
Pectoriloquy ; 
JEgojjhony. 

The  above  is,  essentially, 
the    classification    commonly 
adopted  by  auscultators.  That 
of  Skoda    is,   however,   still 
more  simple.    He  divides  re- 
spiratory sounds  into — 
Vesicular ; 
Bronchial ; 
Amphoric ; 
Indeterminate. 

Skoda  denies,  also,  the  va- 
lidity of  the  distinction  be- 
tween pectoriloquy  and  bron- 
chophony; and  shows  that 
cegophony  cannot  have  the  pre- 
cision of  meaning  supposed  by 
Laennec  and  others  to  belong 
to  it. 

No  description  of  the  sounds 
heard  in  auscultation  can  do 
more  than  guide  and  assist 
their  actual  clinical  study. 
For  this  purpose  the  simplest 
and  clearest  terms  are,  of 
course,  the  best. 

The  normal  respiratory 
murmur,  as  heard  in  the  lungs^  is  well  illustrated  by  Skoda  as 
resembling  (during  inspiration)  the  sound  caused  by  narrowing 
the  opening  of  the  mouth  and  then  drawing  in  the  air.  The  con- 
sonant of  this  murmur  is/  or  p.  The  expiratory  murmur  may  be 
represented  as  somewhat  between  /  and  h.  That  of  the  larynx^ 
trachea^  and  bronchi,  by  the  guttural  c/i,  or  between  that  and  h. 
The  vesicular  murmur  is  slightly  louder  (Flint)  and  lower  in 
pitch,  on  the  left  side. 

By  bronchial  respiration  as  a  sign  of  disease  in  the  lung,  we 
mean  a  breathing-sound  heard  while  listening  over  the  lung,  like 
that  normally  heard  when  auscultating  the  middle  regions  of  the 
chest,  over  the  bronchial  tube.  It  occurs  when  the  lung  is  solidi- 
fied or  condensed.     (The  explanation  of  bronchial  respiration  is  by 


,  Supraspinous.  12.  Scapular  or  sub- 
spinous. 13.  Interscapular  (right 
and  left).  14.  Infra-scapular.  15. 
Inferior  dorsal  (right  and  left).  16. 
Lumbar  (right  and  left).     (Paxton.) 


106 


SEMEIOLOGY, 


conduction  or  by  consonance.  The  latter  theory,  that  of  Skoda,  is 
preferred.) 

Cavernous  respiration  is  that  which  is  inferred  to  occur  during 
the  passage  of  air  into  or  out  of  a  cavity  in  the  lung  (as  in  tuber- 
cular disease).  Notwithstanding  the  truth  of  the  statement  urged 
by  Skoda,  that  it  is  often  impossible  to  draw  a  certain  demarcation 
between  bronchial  and  cavernous  respiration,  yet,  in  a  number  of 
cases  this  can  be  done,  and  the  term  cavernous,  therefore,  should 
be  retained. 

Vesiculo-cavemOTis  respiration  (Flint)^  unites,  in  the  inspira- 
tory sound,  the  qualities  of  vesicular  and  of  cavernous  respiration. 
It  is  sometimes  heard  when  a  cavity  is  surrounded  (not  by  solidi- 
fied but)  by  healthy  lung. 

Of  the  secretory  sounds,  the  sibilant  and  sonorous  rhonchi  are 
the  results  of  narrowing  and  obstruction,  by  congestion,  or  by 
mucus,  etc.,  of  the  bronchial  ramules  ;  of  the  smallest,  in  the  case 
of  the  sibilant  or  whistling  rhonchus ;  of  those  somewhat  larger^  so 

Fig.  43. 


Percussion  tymp- 
anitic; absent  respi- 
ration ;  absent  vocal 
resonance ;  absent 
vocal  fremitus. 


Splash  on  being 
shaken ;  percussion 
dulness ;  metallic 
tinkling. 

Diagram  of  the  Physical  Signs  in  Pneumothorax.     (Dobell.) 

that  the  air  passes  through  in  irregular  and  varying  bubbles,  in 
the  sonorous  (snoring  or  roaring)  rhonchus.  Both  of  these  sounds 
are  characteristic  of  bronchitis.    The  use  of  the  term  dry  sounds. 


1  Manual  of  Auscultation  and  Percussion,  2d  edition,  Fhilada.,  1880. 


AUSCULTATION.  107 

as  applied  to  them,  is  not  strictly  correct ;  but  it  is  convenient, 
as  desif^nating  the  impression  which  they  convey  to  the  ear  as 
compared  with  those  technically  called  moist  sounds. 

The  dry  crackle  is  associated  with  inci'pient  or  infiltrated  tu- 
ber de. 

Among  the  moist  sounds,  the  finest  or  most  delicate  is  the 
crepitant  rSle,  or  fine  crepitation  of  pneumonia.  It  is  very  well 
imitated  by  rubbing  a  few  hairs  of  one's  head  between  the  thumb 
and  finger,  near  the  ear.  Its  caxise  is,  probably  (C.  J.  B.Williams), 
the  penetration  of  the  air  into  the  air-cells  of  the  lung  at  a  time 
when  their  walls  are  rendered  slightly  adhesive  by  effusion  of 
coagulable  lymph.  The  gentle  forcing  apart  of  these  adherent 
walls,  or  of  portions  of  the  viscid  lymph  itself,  produces  the  fine 
crackling  sound,  as  a  modification  of  the  natural  vesicular  mur- 
mur. It  is  only  heard  during  inspiration;  and,  in  children,  with 
difficulty  in  any  case. 

Coarse  crepitant  or  "  mucous"  rales  are  heard  whenever  any 
fluid  exists  in  the  lungs  in  quantity  sufficient  to  modify  respira- 
tion without  arresting  it,  whether  the  fluid  be  mucus,  blood,  or 
sei'ous  effusion. 

The  humid  crackle  or  gurgling  is  pathognomonic  of  advanced 
tuberculization  or  pulmonary  disintegration.  It  is  heard  during 
the  later  stages  of  nearly  all  cases  of  consumption. 

Friction  or  to-and-fro  sounds  are  produced  by  the  rubbing  of 
two  surfaces,  as  of  the  pleura  or  pericardium,  when  made  adhe- 
rent or  slightly  roughened  by  inflammatory  lymph.  It  sometimes 
requires  an  acute  and  practised  ear  to  discriminate  these  from 
other  sounds.  They  are  heard  both  with  inspiration  and  expira- 
tion. 

Broncliopliony,  or  bronchial  vocal  resonance,  corresponds  in  its 
history  with  bronchial  respiration.  It  is  simply  a  resonance  of  the 
voice,  to  the  ear  of  the  auscultator  placed  over  the  lung  of  the 
patient  while  he  speaks,  loud,  near,  and  clear,  as  it  is  normally 
when  the  ear  is  placed  over  the  h-onchial  tube.  The  same  reason- 
ings will  apply  to  the  explanation  of  this  sign  by  the  two  theories 
of  conduction  and  consonance,  which  have  been  urged  in  regard  to 
bronchial  respiration.  The  latter  theory,  as  in  that  instance,  I 
prefer ;  but,  practically,  all  agree  as  to  the  circumstances  under 
which  the  sign  occurs  (solidification  of  the  lungs).  Normally,  the 
vocal  resonance  is  loudest  under  the  right  scapula.  Modifications 
of  the  sound  of  the  whispered  voice  are  spoken  of  by  Dr.  Flint  as 
exaggerated  bronchial,  amphoric,  and  cavernous  whisper. 

Pectoriloqiiy  (chest  speaking)  is  merely  a  yet  nearer  and  louder 
resonance  of  the  voice,  heard  on  auscultation,  than  that  called 
bronchophony ;  the  sound  seeming  to  be  vocalized  in  that  part  of 
the  lung  which  is  immediately  under  the  ear.  Skoda  objects  that 
this  cannot  be  definitely  distinguished  from  loud  bronchophony. 
But,  although  this  is  generally  true,  a  certain  number  of  cases 
occur  in  which  it  may  be  so  distinguished,  as  indicative  of  a  very 
different  pathological  state  of  the  lungs,  viz.,  a  large  cavity. 

^gophony,  bleating,  or  goat-like  resonance  of  the  voice,  has 
been,  since  Laennec,  supposed  to  be  an  almost  certain  sign  of  the 


108  SEMEIOLOGY. 

existence  of  pleuritic  effusion  or  hydrothorax.  Skoda's  observa- 
tions, and  those  of  others  also,  show  that  it  is  occasionally  heard 
in  pneumonia,  in  phthisis,  and  even  in  the  healthy  s^ate  of  the 
thoracic  organs.  It  is,  therefore,  not  pathognomonic  of  the  pres- 
ence of  fluid  within  the  pleura  ;  but  it  is  among  the  signs  which 
render  that  diagnosis  probable. 

Amphoric  resonance  is  heard  especially  in  connection  with  the 
sound  produced  by  coughing.  A  tense  condition  of  the  walls  of  a 
large  cavity  will  explain  it,  as  well  as  the  phenomena  called 
metallic  echo  of  the  voice  or  cough. 

Metallic  tinkling  is  usually  accounted  for  by  the  dropping  of 
fluid  in  a  large  cavity  (as  in  hydropneumothorax,  with  collapsed 
lung)  having  tense  walls. 

Resuming  the  consideration  of  respiratory  sounds,  puerile  or 
exaggerated  respiration  occurs  in  the  healthy  lung,  or  part  of  the 
lung,  when  the  other  lung  or  portion  of  the  same  is  obstructed,  as 
by  a  foreign  body,  or  by  bronchitis  ;  or  condensed,  as  by — 

Pneumonia  ;  Pleuritic  effusion ; 

Tuberculization ;  Tumor. 

A  lung,  a  portion  of  which  is  permanently  expanded  by  emphy- 
sema or  hypertrophied,  may  also  give  an  exaggerated  vesicular 
murmur  ;  and,  transiently,  this  is  observed  in  a  lungjwsi  released 
from  the  paroxysmal  obstruction  of  asthma. 

Feeble  respiratory  murmur  is  heard  in  one  or  both  lungs  in 
cases  of — 

Croup  ;  Collapse  of  lung  ; 

Foreign  bodies  in  air-passages ;     Pulmonary  apoplexy ; 

Bronchitis;  Emphysema; 

Pneumonia;  Pneumothorax ; 

Pleurisy;  Hydrothorax ; 

Asthma  ;  Intercostal  rheumatism  ; 

Infiltrated  tubercle  ;  Paralysis ; 

Cancer  ;  or  other  tumor. 
In  cases  of  pleuritic  effusion,  the  feebleness  of  the  respiratory 
sound  is  proportioned  not  only  to  the  amount  of  fluid  present, 
compressing  the  lung,  but  also  (Baccelli)^  to  the  nature  of  the 
fluid.  Pus  (empyema)  conducts  sound  worse  than  limpid  serous 
effusion.  Baccelli  states  that,  while  even  the  whispered  voice 
may  be  heard  at  the  base  of  a  serous  effusion,  the  spoken  voice  is 
not  heard  over  a  purulent  exudation. 

Harsh,  respiratory  murmur,  passing  by  gradations  into  blowing 
and  bronchial,  in— 

Dry  bronchitis ;  Pneumonia; 

Incipient  tubercle  ;  Pulmonary  apoplexy ; 

Pleurisy  (condensing  lung) ;  Bronchial  dilatation. 

Cavernous  respiration,  in  case  of— 

Tubercular  cavity; 

Excavation  from 

Abscess  of  lung ;  Softening  of  cancer ; 

Gangrene  ;  Large  bronchial  dilatation, 

1  Med.  Times  and  Gazette,  March  18, 1876. 


AUSCULTATION.  .109 

Amphoric  respiratory  sound  is  particularly  associated  with  the 
existence  of  a  listulous  openin<jj  between  the  pleural  cavity  and 
one  of  the  bronchial  tubes ;  the  cause  of  which  tistuia  may  be 
either  tuberculous  softening,  or  abscess,  etc. 

The  sibilant  and  sonorous  rhonchi  occur  nearly  always  in  hmn- 
chitis;  occasionally  in  pulmonary  cmphi/iierna,  and  when  tlie  bron- 
chi are  pressed  upon  by  tumors,  etc. 

Dry  crackling  indicates  the  existence  of  hard  tubercle  in  the 
lun^s. 

Humid  crackling'  or  gurgling,  tubercle  in  the  softened  state. 

The  crepitant  rSle  has  already  been  explained  as  peculiar  to 
pneumonia. 

The  coarse  crepitant*  rale,  or  mucous  rale,  is  observed  fre- 
quently in 

Capillary  bronchitis;  Pulmonary  hemorrhage; 

Bronchorrhoea ;  Pulmonary  oedema; 

Last  stage  of  pneumonia;  Pulmonary  abscess. 

Friction-sounds  have  been  before  alluded  to  as  connected  with 
pleurisi/  and  pericarditis. 
Resonance  of  the  voice  is  feeble  in 

Emphysema;  Atrophy  of  the  lung;  Pneumothorax;  lower 
part  of  chest  in  empyema. 

Bronchophony  occurs  in  cases  of 
Tubercle  ; 

Hepatization  (pneumonia) ; 
Pleurisy  (condensing  lung) ;   Cancer; 
Dilatation  of  bronchi, 

^gophony,  in 

Pleurisy;  Hydrothorax  ;  Pneumonia. 

Pectoriloquy,  in  cases  of 
Tubercular  cavity ; 
Dilatation  of  bronchi  ; 
Excavation  from 
Abscess ;  Cancer ;  Gangrene. 

Metallic  tinkling  and  echo,  in 

Pneumohydrothorax ; 
Large  tubercular  cavity. 

The  sounds  of  the  heart  are  heard  at  an  unusual  distance  from  the 
heart  itself  in  some  cases  of 

Pneumonia ;  Pleurisy ; 

Tubercle ;  Cancer,  etc. 

(This  affords  some  argument  for  the  conduction  theory  of 
Laennec.) 

Displacement  of  the  heart,  diaphragm,  liver,  spleen,  stomach, 
sometimes  occurs  from  pleuritic  effusion  or  empyema,  cancer  of 
the  lung,  etc.     In  rare  instances,  such  a  displacement  may  be 

1  The  term  si(6-crppitaiit  r&le  or  rhonchus  apj)cars  to  the  author  to  bo  very  objection- 
able, as  leading  to  confusion. 

10 


110  SEMEIOLOGY. 

congenital;  as  of  the  heart  on  the  right  side.  A  case  has  been 
reported  by  Leidy,  in  which  the  situation  of  all  the  viscera  was 
reversed  ;  the  liver  being  upon  the  left  side,  the  heart  and  spleen 
upon  the  right,  the  stomach  being  reversed  also,  and  the  ileum 
terminating  on  the  left  side,  the  colon  ending  in  the  rectum  on 
the  right  side.* 

Diseases  of  the  Heart. 
The  physical  diagnosis  of  diseases  of  the  heart  is  conducted 
Fig.  44. 


Normal  position  of  Heart  in  a  healthy  Man.     (Sibson.) 

upon  exactly  the  same  principles  as  that  of  affections  of  the 
lungs  and  pleura. 

1  Proceedings  of  Phila.  Acad,  of  Nat.  Sciences,  1870,  No.  3,  p.  134. 


A  U  S  C  U  I/r  A  T  I  O  N  .  Ill 

By  inspection  wo  can  dotoet  hulsiiif;^  or  distortion  in  tlie  prjB- 
cordial  region,  and,  in  some  cases,  judge  of  the  extent,  force,  and 
character  of  the  heart's  mqndse.  By  mensuration,  changes  in  the 
thoracic  dimensions  consequent  upon  diseases  of  the  heart  can  be 
more  accurately  determined. 

By  palpation,  the  wqmhe  of  the  heart  may  always  be  exam- 
ined and  estimated.  This  is  very  important,  not  only  in  actual 
diseases  of  the  heart,  but  also  in  fevers,  etc.,  in  the  course  of  which 
the  movements  of  the  heart,  as  the  centre  of  the  circulation,  are 
often  seriously  atfected. 

In  hypertrophy,  this  impulse  is  increased  in  force;  in  dilatation, 
it  is  extended;  in  atrophy  and  exhaustion,  it  is  diminished. 

Percussion  aids  us  in  detecting  some  very  important  patholog- 
ical changes  in  the  heart ;  as  hypertrophy,  dilatation,  pericarditic 
effusion.  The  percussion-resonance  is  unusually  clear  in  atrophy  of 
the  heart. 

In  auscultation  of  the  heart  there  is  often  a  decided  conveni- 
ence, although  no  actual  necessity,  in  the  use  of  the  stetho- 
scope. The  learner  must  in  the  first  place  make  himself  familiar 
with  the  natural  sounds  of  the  heart. 

The  first  sound  is  the  longest  and  loudest;  the  succession 
being  imitated  by  the  syllables  luhb,  chip.  If  the  time  from  the 
commencement  of  one  pulsation  to  that  of  another  be  divided 
into  five  equal  parts,  two  of  them  will  be  occupied  by  the  first 
sound,  one  by  the  second,  and  two  by  the  interval  of  repose. 

The  first  sound  accompanies  the  systole  or  contraction  of  the 
ventricles;  the  impulse  of  the  heart  occurs  at  the  same  moment. 
The  second  sound  is  diastolic  as  regards  the  ventricles. 

The  causes  of  the  first  sound  are  believed  to  be  the  contrac- 
tion of  the  powerful  ventricular  muscles,  the  tensioyi  of  the  closed 
auricula-ventricular  valves,  the  rush  of  blood  into  the  great  ves- 
sels, and  the  impulse  of  the  heart  against  the  walls  of  the  chest. 

The  cause  of  the  second  sound  has  been  proved  to  be  the  fiap- 
2jivg  together,  during  the  diastole  or  dilatation  of  the  ventricles, 
of  the  pocket-like  semilunar  valves  of  the  aorta  and  pulmonary 
artery. 

The  essential  points  in  the  "medical  anatomy"  of  the  heart 
are  as  follows  :  — 

The  semilunar  valves  of  the  pulmonary  artery  lie  behind  the 
junction  of  the  cartilage  of  the  third  rib  with  the  sternum. 

The  semilunar  valves  of  the  aorta  are  just  below  these,  between 
the  cartilages  of  the  third  and  fourth  ribs. 

The  tricuspid  or  right  auricido-ventricular  valve  is  behind  the 
sternum,  on  a  level  with  its  articulation  with  the  fourth  rib. 

The  mitral  or  left  auricido-ventricular  valve  lies  behind  the  car- 
tilage of  the  fourth  rib,  a  little  to  the  left  of  the  sternum. 

The  hearths  apex  strikes,  during  the  impulse,  at  a  point  just 
below  the  left  nipple.  The  point  of  greatest  dulness  on  percus- 
sion is  slightly  within  the  left  nipple.  The  diameter  of  the  nor- 
mal region  of  dulness  does  not  exceed  two  inches. 

Using  terms  of  convenience  merely,  the  valves  of  the  heart  may 
be  said  to  be  of  two  kinds,  cavity  valves  and  vessel  valves.  The 
cavity  valves  are  both  nearer  to  the  middle  and  apex  tlian  to  the 


112 


SEMEIOLOGY. 


b^se  of  the  heart;  the  vascular  valves  (aortic  and  puhnonary 
arterial)  nearer  to  its  base,  i.  e.,  as  the  heart  is  situated  in  the 
chest,  its  upper  part. 
By  auscultation  of  the  heart  we  may  detect  valvular  murmurs^ 


Fig.  45. 


Increased  dul- 
ness  on  percus- 
sion, of  pyra- 
midal shape. 


Impulse  less- 
ened. 


Sounds  feeble, 
especially  the 
first. 


^j^jr— 


Position  of  the  Pericardium  when  distended  with  fluid. 
A.  The  Heart.    B.  The  Lungs,     c.  The  Liver.     (Sibson.) 

anaemic  murmurs,  and  Motion  sounds.  Details  in  regard  to  these 
can  be  best  given  in  connection  with  the  special  pathology  of  the 
heart.     A  few  main  points  only  require  mention  here. 

The  valves  of  the  left  or  s^ystemic  portion  of  the  heart  are  much 
more  often  affected  by  disease  than  those  of  the  i-iyht.  Practically, 
in  luost  eases,  those  of  the  right  side  may  be  left  out  of  the  ques- 
tion of  diagnosis. 

The  following  is  Harvey's  statement  of  the  comparative  fre- 
quency of  the  different  valvular  affections  : 

1.  A.ortic  obstructive. 

2.  Mitral  Beyuryitant. 

3.  Aortic  Beyuryitant. 

4.  Aortic  obstructive  and  mitral  regurgitant  together. 

5.  Aortic  obstructive  and  regurgitant  together. 


AUSCULTATION. 


118 


If  a  murmur  (not  ana'niu;)'  is  systolic,  i  e.,  is  heard  witli  the 
first  sound  of  the  heart,  and  is  loudest  at  the  base  of  the  hea^t, 
it  may  be  inferred  to  be  aortic  obstructive. 

If  systolic,  and  loudest  at  the  apex,  mitral  regurgitant. 

If  diastolic,  i.  e.,  with  the  semnd  sound^  ancT  loudest  at  the 
base  of  the  heart,  aortic  regurgitant 

If  diastolic,  and  loudest  at  the  apex,  mitral  obstructive. 

A  presystolic  (auHctdar-systoUc)^  murmur  (Gairduer;,  lliat  is, 

Fig. 46. 


2^S0UND 


Diagram  of  Heart's  Action.     (Guirdner.) 

one  heard  after  the  second  sound,  and  just  before  the  first,  indi- 
cates contraction  of  the  mitral  valve. 

This  opinion,  at  least,  has  been  accepted  by  Drs.  Grairdner, 
Peacock,  Wilks,  and  others  ;  although  Dr.  A.  Whyte  l^arclay^ 
asserts  reasons  for  believing  that  the  sound  referred  to  is  a  sys- 
tolic regurgitant  murmur. 

Duplication  of  the  second  sound  is  reasonably  ascribed  to  the 
closure  of  the  valves  of  the  aorta  and  of  the  pulmonary  arter}'  not 
being  synchronous.  The  condition  with  which  it  is  most  likely 
to  be  associated  is  mitral  obstruction. 

The  rationale  of  these  inferences  is  explained  by  the  physiology 
of  the  heart's  action,  in  connection  with  the  position  of  the  sev- 

1  Dr.  Da  Costa  has  shown,  however,  tliat  functional  murmurs  (attended  hy  no  organic 
lesion)  are  occasionally  heard  in  persons  not  anaemic.  See  American  Journal  ol  JWed. 
Sciences,  July,  1869. 

*  London  Lancet,  March,  1872. 

10*  H 


114 


SEMEIOLOGY. 


eral  valves.     The  fact  that,  in  rare  instances,  organic  murmurs 
vary,'  from  time  to  time,  in  the  same  case,  is  sometimes  perplexing. 


Fig.  47. 


(Gairdner.) 
Fig.  48. 


(Gairdner.) 
Fig.  49. 


Ve  NTRI  CULARHOIASTOLIC     MU  RMUR 


(Gairdner.) 

Murmurs  not  connected  with  valvular  disease  may  be  quite  vari- 
able. 

Dr.  J.  H.  Hutchinson  has  emphasized  the  fact  that  ancemic 
murmurs  are  commonly  most  intense  in  the  recumient  position. 
But  this  is  also  true  in  a  certain  number  of  cases  in  which  the 
murmurs  are  due  to  organic  disease. 

Much  complexity  attaches  necessarily  to  the  exact  diagnosis  of 
affections  of  the  heart ;  but  we  have  the  excellent  authority  of 
Dr.  Stokes  for  the  principle,  that  the  important  practical  questions 

1  Sfie,  on  this  subject,  a  paper  by  Dr.  Sanders,  JSdjn.  Medical  Journal,  Jan.,  1869,  p.  584. 


AUSCULTATION.  .    115 

in  each  case  are — do  the  abnormal  sounds  have  origin  in  organic 
disease  or  lesion,  or  not  ?  and,  how  far  is  the  functional  action 
and  capacity  of  the  heart  interfered  with  or  impaired  ? 

Upon  these,  as  upon  all  other  questions  in  diagnosis,  it  is  proper 
never  to  confine  our  atlention  to  ])hysical  or  immediate  signs  alone. 
To  rest  either  upon  symptomatology  or  physical  exploration 
exclusively^  would  be  like  hopping  constantly  on  one  foot,  instead 
of  walking  upon  two. 

Friction-sounJ.s,  in  the  region  of  the  heart,  are  connected  with 
pericarditis.  Their  narrow  limits,  and  association,  in  time,  with 
the  sounds  of  the  heart,  serve  usually  to  contrast  them  with  pleu- 
ritic sounds.  It  is  sometimes  ditflcult  to  distinguish  them  from 
valvular  murmurs. 

Extra-cardiac  blowing  sounds  (soriffles)  were  mentioned  by  Laen- 
nec,  and  have  been  since  studied  by  others,  especially  Friederich 
and  Potain.'  They  are  explicable  by  the  air  in  the  lung-vesicles 
near  the  heart  being  forcibly  and  audibly  expelled  by  the  move- 
ment of  the  heart.  Vascidar  murmurs  ivithin  the  lungs  have  been 
reported  by  Bartels  ^  and  A.  Stille.^    They  are  very  rare. 

The  signs  of  aneurism  of  the  thoracic  aorta  will  be  alluded  to 
in  another  place.  They  are  chiefly  :  1.  A  second  impulse  (often 
with  a  thrill),  apart  from  that  of  the  heart.  2.  Dulness  on  per- 
cussion. 8.  Bulging.  4.  Symptoms  of  dyspnoea,  cough,  and  dys- 
phagia, from  pressure  upon  the  trachea,  oesophagus,  etc. 

Abdominal  Diseases. 

The  physical  diagnosis  of  abdominal  aflfections  comprises 
inspection,  mensuration,  palpation,  percussion,  and  auscultation. 
The  belly  is  divided,  externally,  into  the  epigastric,  umbilical, 
hypogastric,  two  hypochondriac,  two  lumbar,  and  two  iliac  regions. 
(ISeeFig.  42.) 

^y  abdominal  inspection  we  can  observe  the  alteration  in  size 
and  shape  caused  by  pregnancy,  hernia,  tympanites,  ascites,  or  ova- 
rian dropsy.  By  mensuration,  we  can  ascertain  the  exact  changes 
which  may  occur  from  time  to  time  in  dropsical  accumulations, 
etc. 

By  palpation  of  the  abdomen,  we  may  develop  the  symptom 
of  local  tenderness  on  pjressure ;  as  in  gastritis,  hepatitis,  peritonitis, 
cystitis,  etc.  By  the  same  method  of  examination,  more  deeply 
employed,  we  detect  enlargement  of  the  liver  or  spleen,  ovarian 
tumor,  mesenteric  disease,  cancer,  aneurism,  distension  of  bladder,  fecal 
accumulation,  etc.;  and,  with  the  aid  of  both  hands,  prove  the 
presence  of  fluid  (ascites,  etc.)  by  the  sign  oi'  fluctuation. 

Percussion  assists  materially  in  the  diagnosis  of  diseases  of  the 
abdominal  viscera.  The  ordinary  percussion-resonance,  in  health, 
is  clear,  full,  and  slightly  tympanitic,  all  over  the  abdomen.  It 
bt'comes  more  drum-like  in  distension  of  the  intestines  with  gas 
(meteorism),  or  in  tympanitic  distension  of  the  peritoneum.  Dul- 
ness of  resonance  occurs,  with  limits  and  peculiar  characters,  in 


I  See  a  paper  bv  R.  Lepine,  Gazette  Medicale  de  Paris,  No.  26, 1872. 
a  Prairer  Viertcljahrsc-hrift,  1870,  Bd.  iv. 
8  Pbiladelpliiu  Med,  Times,  April  15,  1871. 


116  SEMEIOLOGY. 

enlargement  of  the  liver  or  spleen,  ascites,  ovarian  dropsy,  pregnancy, 
cancer,  aneurism,  retention  of  the  urine,  fecal  a.ccumulntion,  etc. 

Auscultation  of  the  abdomen  is  especially  useful  in  the  diag- 
nosis of  pregnancy,  by  detecting  the  sounds  of  the  foetal  heart, 
and  the  placental  souffle. 

A  localized  "  bruit  "  or  aortic  murmur,  heard  along  the  spine, 
is  a  probable  sign  of  aneurism  of  the  abdominal  aorta. 

Morbid  sounds  are  occasionally  appreciable  in  other  abdominal 
affections,  as  in. tapeworm,  etc.;  but  they  are  subject  to  so  much 
uncertainty  as  to  be  hardly  available  for  practical  purposes. 
Friction  sounds  in  peritonitis  have  been  studied  by  Dr.  Seidel. 

Eecto-abdominal  exploration  fGustav  Simon,  1872)  is  sometimes 
resorted  to,  by  the  introduction  of  the  hand  through  the  anus, 
into  the  large  intestine ;  occasionally  as  far  as  the  arch  of  the 
colon.  The  hand  must  be  first  well  anointed  with  lard ;  the 
fingers  are  then  placed  so  as  to  make  a  cone,  and  passed  into  the 
rectum  with  the  back  of  the  hand  toward  the  sacrum.  Pronation 
may  be  effected  at  the  sigmoid  flexure.  Aneurism,  cancer,  or 
other  tumors,  etc.,  may  thus  be  detected  and  located.  This 
method  is  not  without  danger.  Once,  at  least  (Dittell),  rupture 
of  the  rectum  has  attended  it. 

Diagnosis  of  Diseases  of  Women, 

Rational  signs  or  symptoms,  and  the  past  history  of  the  patient, 
are  never  to  be  overlooked.  Among  the  questions  to  be  answered 
in  the  case  of  suspected  uterine  or  ovarian  disease,  are  these : 
Has  the  patient  been  married ;  if  so,  how  loug  ?  Has  she  had 
children  ;  how  many  ?  Did  she  ever  miscarry  ?  Is  she,  now, 
probably  pregnant  ?  If  not,  is  menstruation  regular  in  frequency, 
amount,  and  absence  of  suffering  ?  Is  there  any  vaginal  dis- 
charge (leucorrhoea)  ?  What  are  the  symptoms  of  her  present 
complaint,  and  what  have  been  their  duration  and  progress  ? 

Physical  Examination. 

Better  than  a  bed  will  be  a  table,  covered  with  one  or  two 
blankets  or  a  shawl,  and  a  pillow.  If  a  bed  be  used,  its  uneven- 
ness  may  be  remedied  by  placing  a  board  over  the  mattress  and 
under  the  bedclothes.  In  either  case,  a  sheet  should  be  thrown 
over  the  patient  to  prevent  unnecessary  exposure  of  the  person. 

At  first,  the  patient  should  lie  on  the  back,  with  the  knees 
drawn  up  ;  in  a  position  affording  a  strong,  direct  light.  For 
some  methods  of  examination,  the  prone  position,  on  the  hands 
and  knees,  has  decided  advantages. 

The  modes  of  diagnosticating  abdominal  and  pelvic  affections 
in  the  female  by  physical  examinations  are  as  follows  : — 

1.  Yaginal  touch. 

2.  Bimanual  palpation. 

3.  Rectal  touch. 

4.  Vesico-rectal  explovation. 

5.  The  speculum. 

6.  The  uterine  probe. 

7.  Dilating  tents. 


THE    S  P  E  C  U  I>  U  Af  , 


117 


8.  The  exploring  needle. 

9.  Auscultation  and  percussion. 
10.  The  microscope. 

Space  is  not  allowed  in  this  work  to  treat  of  many  particulars 
concerning  those  methods.  ,Thc  student  is  referred,  in  regard  to 
them,  and  for  full  information  uppn  all  the  surgical  diseases  of 
women,  to  the  treatises  of  Thomas,  Sims,  Simpson,  Hewitt, 
Churchill,  Hodge,  Meigs,  Bedford,  Byford,  Agnew,  Atlee,  Barnes, 
Emmet,  and  others,  on  the  general  subject  or  on  the  different 
departments  of  Gynaecology. 

Besides  the  vaginal  touch,  himanual  palpation  and  the  speculum 
are  the  most  important  means  available  for  the  detection  of 
uterine  affections  ;  e.  g.,  displacements,  ulcerations,  tumors,  etc. 

In  cases  of  abdominal  enlargement,  the  following  is  a  compact 
statement  (Jovini)  of  the  method  of  diagnosis  "by  exclusion:" 

"  First,  exclude  pregnancy,  uterine  and  extra-uterine  ;  then 
consider  whether  or  not  there  may  be  an  immense  deposit  of  fat 
on  the  abdominal  walls.  You  do  this  by  lifting  up  the  skin 
between  your  hands.  Next  think  of  tympanites.  When  you 
have  gone  thus  far,  decide  by  palpation  whether  the  tumor  is 
liiiid  or  solid.  If  it  is  solid,  it  is  in  all  probability  either  a  fibroid 
of  the  uterus,  an  enlarged  liver,  or  enlarged  spleen.  If  it  is  fluid, 
it  is  either  ascites,  an  ovarian  cyst  or  fibro-cystic  tumor  of  the 
uterus,  a  distended  bladder,  hydatids  of  some  of  the  viscera, 
pyonephrosis,  or  abscess.  The  most  common  forms  of  abscess 
are  abscess  in  the  neighborhood  of  the  ileo-csecal  valve,  abscess 
the  result  of  pelvic  cellulitis,  and  abscess  from  disease  of  the 
pelvic  bones. 

"  When  you  reach  the  point  Fig.  50. 

of  diagnosis  of  a  fluid-tumor, 
you  are  then  justified  in  as- 
pirating the  case  and  exam- 
ining the  obtained  fluid  by  the 
microscope." 

For  exploratory  aspiration, 
in  the  abdomen  or  elsewhere, 
the  common  hypodermic  syringe 
will  usually  answer  very  well. 


The  Speculum. 

Cylindrical  (see  Fig.  53)  and 
valvular  forms  of  the  speculum 
are  used.  Both  have  their  ad- 
vantages and  inconveniences. 
Some  have  two,  others  three 
or  four  valves  or  movable 
portions.  They  are  employed 
not  only  for  inspection  of  the 
uterus  and  vagina,   but  also 

for  the  application  of  probes,  Sims's  Speculum, 

medicaments,  etc.  Sims's  spec- 
ulum is  used  with  the  aid  of  a  depressor.     Thomas  has  modified 
it  so  as  to  fix  the  depressor  in  connection  with  the  blade. 


118 


SEMETOIiOGY. 


The  position  of  the  patient  preferred  for  the  introduction  of 
Sims's  speculum  is  semiprone;  so  as  to  allow  the  abdominal 
viscera  to  gravitate  forward. 


Fig.  51. 


Siras's  Depressor. 
Fig.  52. 


Fergusson's  Speculum. 

The  Uterine  Sound. 

This  is  a  firm  rod  of  metal,  of  such  a  size  and  curve  as  to  enter 
readily  the  uterine  cavity.  It  requires  skill  and  much  care  to 
use  it  safely.  Very  serious  accidents  are  endangered  by  an  over- 
violence  with  it.  As  stated  by  Thomas,  the  facts  which  may  be 
determined  by  it  are  these  : — 

1.  The  capacity  of  the  uterus. 

2.  The  existence  of  growths  within  it. 

3.  Deviations  of  its  canal. 

4.  Displacements,  as  discriminated  from  tumors. 

5.  The  existence  of  endometritis. 

6.  The  mobility  of  the  uterus. 

FiG.  53. 


Sims's  Copper  Sound. 
Fig.  54. 


y^ZZ.      Z) 


Emmet's  Silver  Probe. 


Dilating  Tents. 

These  are  commonly  made  either  of  sponge  or  of  the  sea-tangle 
(laminaria  digitata).     For  the  former  a  good  clean  sponge  is  cut 


THE    LARYNGOSCOPE.  119 

into  conical  pieces  from  two  to  three  and  a  half  inches  in  length, 
and  with  bases  varying  from  the  width  of  the  little  finger  to  that 
of  a  walnut  or  an  egg.  Each  piece  may  be  dipped  in  a  weak  solu- 
tion of  carbolic  acid,  salicylic  acid,  or  oil  of  cloves,  in  glycerin  ; 
then  saturated  with  mucilage  of  gum  Arabic  ;  a  wire  is  next 
passed  through  its  centre,  and  it  is  tightly  wrapped  from  apex  to 
base  with  strong  cord.  Then  the  wire  is  taken  out  and  the 
sponge  is  allowed  to  dry.  After  that  the  cord  is  removed  and 
another  cord  is  passed  through  the  sponge  and  sewed  fast  to  its 
ai)ex.  Dr.  A.  H.  Smith  prefers  a  sponge  tent  with  a  large  point, 
cylindrical  to  its  end  ;  before  introduction,  to  be  covered  with 
moistened  soap,  coated  with  salicylic  acid. 

Fig.  55. 


Sponge  Tent. 

The  advantage  of  the  sea-tangle  tent  is  that  it  affords  no  ani- 
mal matter  to  decompose  and  produce  fetor  or  irritation.  Several 
small  tents  are  better  than  one  large  one.^ 

Some  German  practitioners  (Landau^)  recommend,  instead  of 
sea-tangle,  the  tupelo  (root  and  stem  of  nyssa  aquatica)  for  tents  ; 
asserting  that  they  expand  more  uniformly,  and  to  a  greater 
extent,  while  almost  free  from  tendency  to  produce  septic  infection. 

Dilatation  of  the  uterus  by  tents  is  not  free  from  danger. 
Tetanus  and  peritonitis  have  sometimes  followed  their  employ- 
ment. The  tent  ought  never  to  be  left  in  the  uterus  more  than 
twelve  or,  at  the  longest,  twenty-four  hours  ;  and  the  patient 
ought  to  remain  in  bed  during  that  time  and  for  one  or  two  days 
afterwards. 

The  Laryngoscope. 

Instrumental  aid  in  examining  the  interior  of  the  larynx  was 
first  thought  of  by  Levret,  in  1743.  Laryngoscopic  mirrors  were 
devised  by  Dr.  Babington,  of  London,  in  1829.  Bozzini,  1804; 
Senn,  of  Geneva,  in  1827 ;  Selligues,  Paris,  1832  ;  Baumes,  Lyons, 
1838  ;  Liston,  1840 ;  Avery,  1844 ;  Garcia,  1854,  and  about  the 
same  time  Jacobi,  of  New  York,  gave  attention  to  the  same  sub- 
ject. Tiirck,  of  Vienna,  applied  mirrors  anew  to  diagnosis  in 
1857  ;  but  shortly  afterwards  Czermak  pursued  laryngoscopy  with 
so  much  acuteness  and  energy  as  to  have  associated  his  name 
with  it  pre-eminentlj'. 

1  SurKical-instruraent  makers  prepare  sea-tangle  tents  for  the  use  of  practitioners. 
"  Sammlung  Klin.     Vortrage,  No.  187,  1831. 


120 


SEM BIOLOGY. 


The  apparatus  required  is  a  laryngeal  mirror,  an  illuminating 
mirror,  and  a  tongue  depressor.  Glass  or  polished  metal  may  do 
for  the  mirrors. 

The  laryngeal  mirror  may  be  round  or  square,  preferably  the 
former,  and  about   an  inch  or  less  in  diameter.     It  should  be 

Fig.  56. 

JSTWt —  '       = 


Laryngoscope. 

attached  at  an  obtuse  angle  ("120°  to  125°)  to  a  stem,  which  may  be 
fastened  into  a  slender  handle  so  as  to  be  drawn  out  or  pushed  in. 
The  illuminating  mirror  is  larger  (from  3  to  12  inches  in  diam- 
eter) and  concave,  to  concentrate  reflected  light.  It  may  be  held 
by  a  handle  in  the  operator's  mouth,  or  fixed  by  a  band  to  his 
forehead,  or,  best,  as  used  by  Semeleder,  perforated  in  the  mid- 
dle and  fastened  to  the  bridge  of  a  pair  of  spectacles  (with  or 

Fig.  58. 


Laryngoscopic  drawing,  showing  the 
Vocal  Cords  drawn  widely  apart, 
and  the  position  of  the  various  parts 
above  and  below  the  Glottis  during 
quiet  inspiration,  g.  e.  Glosso-epi- 
glottidean  Folds,  u.  Upper  surface 
of  Epiglottis,  l.  Lip  of  Epiglottis, 
c.  Cushion  of  Epiglottis.  ?;.  Ventricle 
of  Larynx,  a.  e.  Ary-epiglottidean 
Fold.  c.  W.  Cartilage  of  Wrisberg. 
c.  S.  Capitulum  Santorini.  com. 
Arytenoid  Commissure,  v.  c.  Vocal 
Cord.  V.  b.  Ventricular  Band.  p.  v. 
Processus  Vocalis.  cr.  Cricoid  Car- 
tilage. ^  Rings  of  Trachea.  (Mac- 
kenzie.) 

without  the  glasses)  so  as  to  rest  before  one  of  the  eyes  and  be 
looked  through. 
The  laryngeal  mirror  is  introduced  (after  being  warmed  to  pro- 


Laryngoscopic  drawing,  showing  the 
approximation  of  the  Vocal  Cords 
and  the  position  of  the  various  parts 
in  the  act  of  vocalization.  /.  i.  Fossa 
Innominata.  h.f.  Hyoid  Fossa,  c.  h. 
Cornu  of  Hyoid  Bone.  c.  W.  Carti- 
lage of  Wrisberg.  c.  S.  Capitulum 
Santorini.  a.  a.  Arytenoid  Carti- 
lages, com.  Arytenoid  Commissure. 
p.  V.  Processus  Vocalis.  (Mac- 
kenzie.) 


THE    OPHTHALMOSCOPE.  121 

vent  condtmsfition  of  moisture)  so  that  its  bacl<  pushes  the  uvula 
upwards  and  1)aekwards,  its  lower  edL!;e  presses  upon  the  posterior 
wall  of  the  pharynx,  and  its  stem  rests  in  the  angle  of  the  mouth. 

Sunlight,  horizontal  (morning  or  evening),  is  the  best  for  laryn- 
goscopy, but  artificial  light,  as  of  a  good  lamp,  may  suffice. 

The  diJficAilU/  of  the  operation  is  produced  by  the  irritability  of 
the  fauces  and  larynx.  Few  can  allow  of  a  successful  examina- 
tion on  the  first  attempt ;  practice  makes  tolerance.  To  hasten 
this,  bromide  of  potassium  has  sometimes  been  given.  The  fre- 
quent insertion  and  retention  for  a  while  of  the  finger  of  the 
patient  or  of  an  instrument  in  the  fauces  accustoms  the  parts  to 
pressure.  Holding  ice  to  the  throat  just  before  the  examination 
also  lulls  sensibility.  Momentary  use  of  ether  spray  has  been 
resorted  to  for  the  same  purpose. 

By  laryngoscopy,  tumors,  ulcerations,  inflammatory  changes, 
etc.,  iin  the  larynx  may  be  inspected,  topical  applications  made, 
and  surgical  operations  performed,  with  a  precision  not  otherwise 
possible. 

Rhinoscopy  is  the  examination,  in  a  similar  manner,  of  the 
posterior  nares.  It  requires  merely  a  smaller  mirror  (less  than 
three-fourths  of  an  inch  in  diameter)  than  for  laryngoscopy,  and 
at  about  a  right  angle  to  its  handle. 

The  otoscope  (for  the  ear),  and  endoscope  (for  the  urethra), 
etc.,  are  instruments  for  surgical  diagnosis,  not  demanding 
description  here. 

The  Ophthalmoscope. 

Not  only  for  ascertaining  the  state  of  the  eye  in  various  disor- 
ders of  vision,  but  also  to  aid  in  diagnosticating  affections  of  the 
hrain^  this  instrument  has  acquired  importance  in  recent  times. 
Essentially  perfected  by  Helmholtz  (1851),  it  was  brought  forward 
especially  by  Grafe  (1860),  and  has  had  minor  improvements  made 
in  its  use  by  Liebreich,  Anagnostaki,  Zander,  and  others.  It  con- 
sists of  a  concave  circular  mirror  about  two  inches  in  diameter, 
perforated  by  a  small  hole  at  the  centre,  with  which  is  used  also 
a  biconvex  lens  of  two  or  three  inches  focal  length.  The  following 
account  of  the  mode  of  its  employment  is  from  Zander : 

"  In  order  to  effect  a  satisfactory  examination  of  the  eye  with 
the  ophthalmoscope  it  is  essential  to  have  a  good  light.  Artificial 
light,  as  that  from  an  oil  or  gas  lamp,  is  practically  the  best.  In 
preparing  the  patient  for  an  examination  the  pupil  should  be 
dilated  by  atropia,  a  small  quantity  of  a  solution  containing  one- 
twentieth  of  a  grain  of  the  alkaloid  to  the  ounce  of  water  having 
been  applied  to  the  eye  several  hours  before.  The  room  being 
darkened  and  the  patient  seated,  the  lamp  should  be  placed  near 
the  head  of  the  patient,  on  the  same  side  as  the  eye  to  be  exam- 
ined, so  far  back  as  to  leave  the  cornea  in  shadow.  It  is  also 
important  that  the  flame,  the  eye  of  the  patient,  and  the  eye  of  the 
observer  should  be  all  at  the  same  level.  The  observer  now  takes 
the  concave  mirror  in  the  hand  that  is  on  the  side  towards  the 
lamp,  places  its  edge  against  the  superior  margin  Oi"  his  orbit, 
and  looks  through  the  perforation  at  the  eye  to  be  examined ;  he 
then  causes  the  mirror  to  turn  a  little  on  its  vertical  axis,  until 
11 


122 


SEMEIOLOGY. 


the  inverted  image  of  the  flame  is  cast  upon  the  eye  under  exam- 
ination, the  pupil  of  which  will  then  return  a  more  or  less  intense 

reddish  or  whitish  glow.     For 
Fig.  59.  a  general  inspection  of  the  re- 

fracting media,  it  will  be  suffi- 
cient to  look  at  the  eye  from 
different  directions,  and  cause 
it  to  make  slight  movements 
upwards,  downwards,  and  to 
either  side.  If  no  diseased 
conditions  be  apparent,  the 
observer  proceeds  to  examine 
the  inverted  image  of  the  fun- 
dus. For  this  purpose  he  takes 
a  biconvex  lens  of  2''^  or  3^^ 
focal  length,  in  the  thumb 
and  index  of  his  free  hand, 
rests  his  little  finger  upon  the 
forehead  of  the  patient,  and 
brings  the  lens  in  front  of  the 
examined  eye,  so  that  the 
light  from  the  mirror,  passing 
through  the  lens,  will  be  concentrated  upon  the  pupil.  The 
actual  inverted  image  of  the  fundus  wiU  now  be  formed  betwixt 

Fig.  60. 


Ophthalmoscope. 


Representation  of  the  appearances  seen  with  the  Ophthalmoscope  in  a  case  of 
Tubercle  of  the  Choroid,  a.  Tubercle  in  the  Choroid,  b.  Artery  of  the 
Retina,    c.  Veins  of  the  Retina,     d.  Optic  Disk.     (Bouchut.) 

the  lens  and  the  eye,  and  in  the  focus  of  the  former ;  and  to  ren- 
der it  visible,  the  observer  must  usually  move  his  head  somewhat 
further  back.  The  first  object  to  be  sought  within  the  eye  is  the 
entrance  of  the  optic  nerve.  Sometimes  before  its  white  surface 
becomes  visible,  darker  streaks  may  be  seen  traversing  a  bright 


THE    OIMITIIAT.MOSCOPE. 


123 


rod  _c;ronn(l.  Those  will  bo  the  vessels  that  proceed  from  the 
entrance  itself,  and  by  foUowitiij;  one  of  them,  in  tlu;  din^ction  of 
its  increasing  thickness,  towards  the  inner  and  infc^rior  parts  of 
the  eye,  by  movemonts  of  the  observer  and  mirror  in  the  opposite 
directions,  the  wliite  surface  of  the  optic  disk  will  presently  bo 
perceived.  After  insi)ection  of  the  nerve  surface,  attention  should 
next  be  directed  to  the  vessels,  to  observe  whether  they  present 
a  normal  condition  at  their  place  of  enti-ance,  to  note  their  course 
over  the  white  disk,  and  their  conduct  at  and  after  passing  to  the 
red  background.  After  the  vessels,  should  be  observed  the  trans- 
parency of  the  retina,  its  relations  to  the  choroid  ;  and  then  the 
observer  should  return  to  a  more  careful  and  accurate  study  of 
the  entrance  of  the  nerve.  Lastly  follows  the  inspection  of  the 
refractory  media,  the  vitreous  body,  the  crystalline  lens,  the  cor- 
nea, and  then  that  of  the  iris." 

Tiirck  first  called  attention  to  retinal  signs  of  brain  disease,  in 
1858.  Von  Graefe,  in  18G0,  pointed  out  the  existence,  in  dilier- 
ent  cases,  of  two  conditions :  that  of  engorgement  of  the  intra- 
ocular end  of  the  optic  nerve  [stasis  papillcej  or  choked  disk,  and 


Fig.  61 . 


Choked  Disk.     (After  Liebreich.) 


that  of  inflammation  of  the  optic  nerve,  descending  from  menin- 
geal inflammation  {descendiny  optic  neuritis).  In  ninety-five  per 
cent,  of  brain  tumors  (Bouchut,  Ogle,  Earnest  Hart,  Allbutt, 
Ilughlings-Jackson,  Annuske,  Reich,  Longstreth,  Norris,' Shakes- 
peare) one  or  other  of  these  appearances  exists.  Yet,  as  some 
marked  cases  of  brain  tumor  have  been  shown  (Becker,  Schweig- 
ger)  to  be  entirely  without  ophthalmoscopic  signs,  the  most  cer- 
tahi  value  of  their  frequent  coincidence  appears  to  be  negative. 

1  riula.  Med.  TiiiiL's,  Aug.  30,  1S79. 


124 


SEMEIOLOGY. 


That  is,  ivhen  tumor  of  the  brain  is  suspected  hut  not  proven^  the  total 
absence  of  ophthalmoscopic  changes  lessens  greatly  the  probability  of 
its  existence. 

Among  the  abnormal  appearances  shown  by  the  ophthalmo- 
scope, involving  the  eye  itself,  one  of  the  most  interesting  is  the 
cupped  depression  of  the  optic  nerve-disk,  in  connection  with  the 
morbid  tension  of  the  eye-ball  in  acute  glaucoma.  Accompanying 
this  sign,  we  have  evidence  of  undue  tension  on  palpation  of 
the  bafi,  with  marked  redness  from  increased  vascularity,  severe 
pain,  and  rather  sudden  loss  or  impairment  of  vision. 

Atrophic  degeneration  of  the  optic  nerve  may  be  ophthalmo- 
scopically  shown  in  many  cases  of  locomotor  ataxy ^  multiple  cerebro- 
spinal sclerosis,  chronic  alcoholism,  and  nicotism  (tobacco  poisoning). 
In  some  instances  such  a  degeneration  is  the  occasion  of  heredit- 
ary loss  of  sight. 

The  Sphygmograph. 

H^risson,  about  1833,  supported  by  Magendie,  attracted  much 
attention  at  Paris  by  his  sphygmometer  ;^  this  was  a  mercurial  tube, 
ending  in  an  excavated  hemisphere  of  ivory  or  steel,  with  a  sub- 
jacent membranous  portion  made  to  rest  upon  an  artery.  2^^ext 
came,  for  the  visual  study  of  the  pulse,  the  kymographion  of  Lud- 
wig  ;  afterwards,  King's  improvement  upon  it  by  the  use  of  a 
lever  ;  then  the  sphygmograph  of  Vierordt,  and  afterwards,  that 
of  Marey.  The  instrument  of  the  latter  is,  undoubtedly,  at  the 
same  time  the  simplest  and  the  most  accurate. 

It  consists  essentially  of  a  very  delicately  adjusted  lever,  one 
end  of  which  rests  upon  an  upright,  which,  by  a  rounded,  surface, 

Fig.  62. 


Sphygmograph  applied  to  the  Arm. 

presses  on  the  radial  artery  at  the  wrist ;  while  its  free  end  sus- 
tains a  pen,  whose  point  is  placed  in  contact  with  a  strip  of  paper, 
kept  in  steady  motion  by  clockwork.'^  Each  beat  of  the  pulse, 
therefore,  magnified  by  the  lever,  is  registered  in  a  waving  line 
upon  the  paper.  Some  observers  prefer  a  smooth  point  acting 
upon  smoked  glass  for  the  registration. 

1 1  have  before  me  a  copy  of  a  translation  of  Hfirisson's  memoir  presented  to  the 
French  Institute,  published  in  Philadelphia  in  1835,  by  Dr.  J.  G.  Nancrede. 

2  Few  of  our  instrument  makers  yet  construct  the  sphygmograph.  One  may  be  im- 
ported from  Paris  for  about  $40.  Otto  &  Reynders,  of  Now  York,  manufacture  the  im- 
proved instrument  of  Dr.  E.  Holden.  Pond's  sphygmograph,  also,  is  now  made  in  this 
country. 


THE    SPHYGMOGRAPH.  125 

-4 

Much  phj'siological  as  well  as  pathological  interest  attaches  to 
this  mode  of  demonstration  of  arterial  action.  It  has  l)een  care- 
fully studied  1)v  a  number  of  able  observers,  especially  Wolff, 
Naumann,  Onimus  and  Viry,  Bunion  Sanderson,  Anstie,  B.  W. 
Foster,  and  E.  Holden.'  Our  present  concern  with  it  is  in  regard 
to  its  diagnostic  use. 

The  marking  of  the  normal  or  liealthy  pulse  presents  in  regular 
succession  the  following  parts:  1.  An  ascending  line  or  summit 
wave;  2.  A  slight  depression,  or  notch,  rising  very  soon  into  a 
secondary  wave ;  3.  A  deep  impression,  or  great  notch ;  4.  A 
second  great  ascension ;  5.  A  descending  line.  All  authorities 
are  not  quite  agreed  as  to  the  explanation  of  each  of  these  por- 
tions of  the  curve;  which  admit,  moreover,  of  some  variations 
compatible  with  health.  The  following  is  probably  the  correct 
view. 

1,  The  first  ascension  or  summit-wave  follows  immediately  upon 
the  full  commencement  of  the  ventricular  S3'stole,  as  a  "  pressure- 
wave  "  (Weber),  or  vibratile  impulse  communicated  to  the  column 
of  blood  in  the  vessels.  2.  The  secondary  wave  coincides  with 
the  closure  of  the  auriculo-ventricular  valves,  and  the  forward 
impetus  of  the  blood  under  the  total  pressure  of  the  systole. 
3.  The  "great  notch"  ( Wollf)  is  due  (Naumann,  B.  Sanderson) 
to  the  rebound  of  blood  under  the  arterial  contraction  ;  the  reflux 
which  closes  the  aortic  valves.  It  is  sometimes  called  the  aortic 
notch,  4.  The  second  main  ascension  follows  the  closure  of  the 
semilunar  valves  of  the  aorta,  the  arterial  systole  then  taking  its 
full  effect.  5.  A  descending  line  attends  the  subsidence  and  in- 
termission of  the  pulse.^ 

By     variations     from  Fig.  63. 

these   usual    characters 
of  the  sphygmographic 
marking,     evidence     is 
given      in     regard     to 
changes     in  —  1.     The 
force  of  the  heart's  ac- 
tion.   2.  The  tension  of 
the  arteries.    3.  The  ex- 
istence of  obstructions, 
anywhere,  to  the  move- 
ment of  the  blood.    The  p^j^g  Tracins. 
permanent     record    ob-     «  Primary  Wave;  6  Tidal  Wave;- c  Dicrotic 
tainable  by  meansof  the         Wave;  d  Fourth  Wave;   e  Aortic  Notch. 
instrument   gives   great        (Fiulayson.) 
advantage  for  the  com- 
parative study  of  diflerent  cases.     Hence,  hospital  men,  espe- 
cially, should  value  the  sphygmograph. 

In  old  age^  the  pulse-mark  has  generally  a  nearly  vertical  but 
sometimes  broken  ascent,  a  rounded  or  fattened  summit,  deti- 

1  Prize  Essay  on  the  Sphygmograph,  1873.  Room  yet  exists  for  further  investigation 
of  the  same  subject  in  other  modes.  See  a  paper  by  the  author,  Am.  Journal  of  iMi'd. 
Sciences,  July,  1868,  p.  2SS. 

2(iahibin  has  asserted  a  complictifhif!  effect  in  the  sphygmographic  pulso-record  to  bo 
due  to  the  oscillation  of  the  instrument;  but  this  view  is  not  well  sustained. 

11* 


126 


SEMEIOLOGY. 


ciency  in  the  dicrotism  or  second  (arterial)  ascent;  often  a  sudden 
fall  after  the  primary  cardiac  wave. 

In  aneurism  of  either  of  the  great  vessels,  the  sphygmograph 
affords  much  assistance  in  diagnosis.     It  shows  a  loss  of  force  in 


Fig.  64, 


Fig.  64.  Pulse-tracing  of  Radial  Artery,  somewhat  deficient  in  tone. 

Fig.  65.  Firm  and  long  Pulse  of  Vigorous  Health. 

Fig.  66.  Pulse-tracing  of  Radial  Artery,  with  Double  Apex. 

the  pulse  on  the  side  of  the  aneurism,  with  lessening  of  dicrotism  ; 
and,  particularly,  a  difference  in  the  radial  pulse-mark  of  the  two 
sides  of  the  body. 

Aortic  regurgitation  is  attended  by  a  vertical  ascent  of  the  first 
wave,  ending  in  a  point.  This  alone,  however,  is  not,  as  Marey 
and  others  for  a  time  supposed,  decisive  ;  since  functional  dis- 
turbance of  the  heart  may  produce  the  same  effect.  There  is, 
in  aortic  regurgitation,  a  notable  suddeness  in  the  fall  that  fol- 

FiG.  67. 


Pulse  of  Aortic  Regurgitation.     (Finlayson.) 

lows  the  pointed  ascent ;  a  collapse  of  the  artery,  without  the 
dicrotic  vascular  rebound  or  second  ascending  wave.     An  ohlique 
line  of  the  first  ascent  generally  occurs  in  obstruction  of  the  aortic 
valves. 
Mitral  regurgitation  gives  indication  of  a  small,  irregular, 

( 


THE    RPITYGMOGRAPH. 


127 


usually  dicrotic  pulse ;   easily  modifiecl  by  compression  of  the 
artery. 

Variations  in  the  fulness  and  pressure  of  the  arterial  system, 
under  difterent  causes,  will  produce  corresponding:  changes  in  the 
sphygmographic  markings.  ^  This  is  very  quickly  shown  when  the 
pulse  is  registered  while  under  the  influence  of  inhaled  vapors ; 
c.  J/.,  nitrite  of  amyl.  In  acute  diseases  accompanied  by  fever, 
Wolff  and  others  have  described  some  characteristic  sphygmo- 
graphic alterations  ;  which,  however,  require  further  analysis.  It 
is  stated  that,  in  fever,  instead  of  the  three-pointed  (tricrotous) 
pulse,  a  tendency  to  dicrotism  exists  ;  sometimes  to  a  single  wave 
or  monocrotism.  When  the  aortic  notch  is  deepened  moderately, 
so  as  not  to  reach  the  line  of  the  base  of  the  pulse-curve,  it  is  said 
to  be  hiipodkrolous.  If  it  reach  that  line  in  its  descent,  perfecthj 
dicrotmis.  When  it  goes  below  it,  it  is  hyperdicrotous.  Changes 
of  temperature  are  asserted  to  accompany  these  variations  ;  the 
highest  degree,  above  104°,  being  found  usually  with  the  last. 

Anstie     has    recorded, 
also,  the  effects  of  alrohol  Fig.  68. 

on  the  pulse  as  shown  by 
the  sphygraograph.  He 
determined  that,  when  it 
acts  as  a  helpful  stimulant, 
in  typhoid  states,  the  pulse 
is  made  slower,  and  ex- 
cessive dicrotism  is  re- 
duced. When  alcohol  acts 
as  a  narcotic,  it  acceler- 
ates the  pulse  and  in- 
creases dicrotism. 

Always,  a  want  of  uni- 
formity and  regularity  in 
the  pulse-marks,  or  sud- 
den or  great  changes  in 
their  character,  will  be 
significant  of  morbid 
states,  which  may  often 
be  of  serious  importance. 
Still  it  would,  in  the  case 
of  the  sphj'gmograph,  as 
in  that  of  other  instru- 
ments, be  a  great  mistake 
to  allow  it  to  supersede  the 
use  of  the  more  simple 
and  constantly  available 
modes  of  diagnosis.  The 
taciiis  eruditus  must  keep 
its  plac'%  as  indispensable 
to  every  skilful  physician. 

Other  sphy^mograpic  instruments  besides  Marey's  have  been 
invented  and  used  i  Mahomed,  Ilolden  ^.  Pond's  ^  sphygmograph, 
especially,  has  met  with  considerable  favor. 

1  London  Practitioner,  April,  1S79,  p.  298. 


Pond's  Sphygmograph. 


128 


SEME  10  LOGY. 


Dr.    Hawksley^  has   devised    a   "  stetho-sphygmograph,"   by 
which  may  be  observed  and  recorded  not  only'ijeculiarities  or 


Fig.  69. 


Eight  Radial  Pulse  in  a  case  of  Thoracic  Aneurism.     (Finlayson.) 
Fig.  70. 


Left  Radial  Pulse,  in  same.    (Finlayson.) 
Fig.  71. 


Pulse  in  a  case  of  Bright's  Disease.    (Finlayson.) 

modifications  of  the  circulation,  but  at  the  same  time  their  rela- 
tions to  respiration. 

Combination  has  also  been  effected  between  the  sphygmograph 
and  the  cardioyra-ph  (for  record  of  movements  of  the  heart). 
Marey  arranged  this  upon  the  "tambour"  method,  with  air  as 
the  medium  of  transmission.  Others^  have  employed  water  for 
the  same  purpose,  with  similar,  if  not  greater,  success. 


TEMPERATURE   IN  DISEASE. 

The  thermometer  (De  Haen,  1754,  Wunderlich,  J.  Davy)  is  a 
useful  aid  in  diagnosis  and  prognosis,  making  exact  that  infor- 
mation which  every  physician  constantly  obtains  by  the  touch. 
It  is  especially  valuable  in  the  clinical  study  of  febrile  disorders, 
as,  since  Galen,  fever  is  essentially  defined  by  the  words  "pre- 
ternatural heat." 

The  axilla  is  the  best  part  for  examination  of  temperature. 
Some,  however  (Finlayson),  prefer  the  rectum.  In  children, 
this  is  probably  better.     The  instrument  should  be  kept  there 

1  Lancet,  December,  18,  1869 

2  K-eyt,  New  York  Medical  Record,  Oct.  30, 1880,  p.  479. 


TEMPKUATURE    IN     DISEASE.  129 

from  three  to  five  minutes  at  a  time.  Normally,  in  the  armpit, 
the  temperature  averai^es  ^)P>.rp  Fahr.,'  with  a  range  in  health 
(Davy)  from  99°  to  97.9-2.0  It  is  about  1°  hi.gher  in  trop- 
ical than  in  temperate  climates.  In  the  temperate,  it  is  higJieat 
on  waking  in  the  early  mori,iing  ;  lowest  at  midnight.  In  tropi- 
cal regions,  it  is  Irnvest  in  the  early  morning,  and  highest  during 
the  day.-  It  is  one  or  two  degrees  higher  in  children  than  in 
adults  ;  but  in  children  during  health,  according  to  Finlayson, 
it  is  less  in  the  evening  than  in  the  morning. 

A  rise  of  temperature,  in  disease,  of  1°  Fahr.  corresponds,  as 
a  rule,  with  an  increase  of  the  pulse  of  eight  to  ten  beats  per 
minute.  The  thermometer  in  the  axilla  may,  in  some  febrile 
cases,  mark  100°,  108°,  even  112°.  It  has  been  found  highest  in 
scarlet  fever,  yellow  fever  (Dowler),  and  tetanus.  Dr.  H.  C. 
AVood,  found  it  lO'.P  in  the  axilla  of  a  man  dying  with  heat- 
stroke, and  nop  in  his  abdomen  after  death.  Wunderlich 
records  the  temperature  of  112.55°  in  tetanus  at  death,  and 
113.56°  after  death. 

The  most  extraordinary  excess  of  bodily  temperature  has  been 
reported  by  J.  W.  Teale,'^  as  occurring  in  a  case  of  injury  of  the 
spine  by  a  fall.  As  tested  by  eight  different  thermometers,  it 
ranged  for  seven  weeks  above  108°,  and  during  a  number  of  days 
fluctuated  between  116°  and  122°.  But  for  the  concurrent  testi- 
mony of  several  medical  witnesses,  this  account  would  appear 
incredible.  Dr.  Donkin  has  recorded  cases  of  fever,  pneumonia, 
inflamed  stump  of  limb,  and  pyonephrosis,  in  which  temperatures 
occurred  as  high  as  112°,  113°  115°,  and  117°.  All  these 
patients  recovered. 

In  intermittent  fever,  during  the  paroxysm,  even  when  the 
patient  shivers  and  feels  cold  to  himself,  his  heat  by  the  ther- 
mometer is  usually  above  the  natural  degree. 

"  When*  the  temperature  is  increased  beyond  98.5°  it  merely 
shows  that  the  individual  is  ill ;  when  it  is  raised  as  high  as  101°- 
106°,  the  febrile  phenomena  are  severe  ;  if  above  105°,  the  patient 
is  in  imminent  danger ;  with  108°  or  109°  a  fatal  issue  may  with- 
out doubt  be  expected  in  a  comparatively  short  time. 

"A  person,  yesterday  healthy,  who  exhibits  this  morning  a 
temperature  above  104°  Fahr.,  is  almost  certainly  the  subject  of 
an  attack  of  ephemeral  fever  or  of  ague  ;  should  the  temperature 
rise  to  or  beyond  106.3°,  the  case  will  certainly  turn  out  one  of 
some  form  of  malarious  fever.     It  cannot  be  typhoid  fever. 

"  A  patient  whose  temperature  rises  during  tlie  first  day  of  ill- 
ness up  to  105° or  106°  Fahr.,  certainly  does  not  sufter  from  typhus 
or  typhoid  fever.  In  a  patient  who  exhibits  the  general  typical 
signs  of  pneumonia,  but  whose  temperature  never  reaches  101.7° 
Fahr.,  it  may  be  concluded  that  no  soft  infiltrating  exudation  is 
present  in  the  lung. 

"If  a  patient  suffer  from  measles,  and  retain  a  high  tempera- 

1  Aitken  states  it  as  98.4°;  Wunderlich,  98.6°;  my  own  observation  gives  it  98  5°. 
F.  Finlayson  asserts  the  existence  of  greater  variability  of  temperature  in  children. 

2  See  Aitkcn's  Science  and  Practice  of  Medicine,  4th  ed.,  vol.  i.,  p.  39. 
8  London  Lancet,  March  6,  1875. 

*  Aitken,  op.  citat.,  vol.  i.,  p.  44. 

I 


130 


SEMETOLOGY. 


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TEMPERATURE     IN    DISEASE,  131 

ture  after  the  eruption  has  faded,  it  may  be  concluded  that  some 
coniplicatinij;  disturbance  is  present. 

"  In  typhoid  fever,  a  temperature  wliich  does  not  exceed  any 
evening  103.5°  indicates  a  i)robaljly  mild  course  of  the  fever.  105'^ 
in  the  evening,  or  104°  in  the  morning,  shows  danger,  in  the  third 
week.  In  pneumonia,  a  teniperature  of  104°  and  upwards  indi- 
cates a  severe  attack.  In  acute  rheumatism,  a  temperature  of 
104°  is  always  an  alarming  symptom,  foreboding  danger,  or  some 
complication  such  as  pericardial  inflammation.  In  jaundice, 
otherwise  mild,  a  rise  of  temperature  indicates  a  pernicious 
turn.  In  a  puerperal  female,  an  increase  of  temperature  shows 
approaching  pelvic  inflammation.  In  tuberculosis,  an  increase 
of  temperature  shows  that  the  disease  is  advancing,  or  that 
untoward  complications  are  setting  in.^ 

"A  fever  temperature  of  104°  to  105°  Fahr.,  in  any  disease, 
indicates  that  its  progress  is  not  checked,  and  complications  may 
still  occur." 

Certain  diseases  have  been  found  to  have  typical  ranges  or 
daily  fluctuations  of  temperature  throughout  their  course  ;  so  that 
their  " diflerential  diagnosis"  may  be  thus  assisted  materially. 
This  has  now  been  determined,  especially  in  malarious  fever, 
relapsing  fever,  typhus,  typhoid,  smallpox,  scarlatina,  measles, 
rheumatism,  pyaemia,  pneumonia,  and  acute  tuberculosis.  Dr. 
Da  Costa  has  observed  that,  in  some  cases  at  least,  cancer  is 
attended  by  a  lowering  of  temperature. 

The  same  assertion  has  been  made  by  others  in  regard  to  dia- 
betes mellitus.  Dr.  B.  W.  Richardson  found  that  tlie  narcotism 
produced  by  hydrate  of  chloral  is  always  accompanied  by  reduc- 
tion of  temperature.  Alcohol  produces  a  moderate  effect  of  the 
same  kind.  Dr.  Bourneville  has  shown  that  a  considerable  fall 
occurs  in  ursemia.'^  Dr.  Ogle  reports  the  decided  lowering  of  the 
temperature  in  cases  of  phthisis,  under  fifteen  and  twenty-grain 
doses  of  sulphate  of  quinine.*  Many  observations  make  it  appear 
that  large  doses  of  quinine  greatly  lower  the  temperature.  Sali- 
cylic acid  and  oil  of  eucalyptus  also  have  a  similar  effect.  Bella- 
donna and  coftee  increase  the  temperature.  Dr.  Nieden  observed 
the  temperature  to  be  reduced  after  an  injury  of  the  spinal  cord. 

During  the  collapse  of  malignant  cholera,  in  moribund  cases, 
the  temperature  of  the  breatli  has  been  found  to  be  as  low  as  80°, 
or  even  70°.  Recover}^  has  seldom  been  known  from  any  disease 
when  the  temperature  in  the  axilla  has  fallen  below  90°  Fahr., 
except  in  alcoholic  poisoning ;  in  which  Bathurst  Woodman  has 
several  times  seen  recovery  after  that  degree  had  been  reached.* 
Ursemic  coma,  also,  is  attended  by  low  temperature.  Dr.  I. 
Alvarado,  of  Mexico,  has  made  a  study  of  the  relations  between  the 

1  The  statement  (S.  Ringer)  that  rise  of  temperature  alivays  attends  the  deposition  of 
tubercle  is  not  exact.  Wiiuderlich,  Roser,  Herard,  Cornil,  Jenner,  and  otliers,  have 
sliown  many  exceptions  to  it.  In  Brit.  Med.  Journ.,  April  5,  1873,  a  case  is  reported  as 
occurring  under  the  care  of  Sir  W.  Jenuer,  in  wliicli  fatal  acute  tuberculosis  occurred 
u-Hliont  any  pyrexia. 

2  Sec  Ham/t,  Lancet,  .Tan.  4,  1873.  3  London  Lancet,  July  6,  1872. 

*  Dr.  Mendelson  found  a  temperature  of  90°  F.  in  the  rectum  ot  a  half-starved  insane 
patient  in  the  N.  Y.  Hospital,  in  April,  1881;  he  recovered  under  stimulation  with 
nutriment. 


132 


SEMEIOLOGY. 


temperature  and  the  pulse^  in  health  and  disease,  which  may,  when 
completed,  be  of  value  in  diagnosis  and  prognosis.^ 

Fig.  73. 


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Diurnal  range  of  Temperature  in  Hectic  Fever.     (Finlayson.) 

In  relapsing  fever,^  the  heat  rises  quickly  in  the  first  stage, 
reaching  104°  or  105°  on  the  second  day  ;  fluctuating  then  until 
the  day  before  the  defervescence,  when  it  attains  its  highest  point ; 
sometimes  107°  or  108°.  Then  it  sinl-;s  rapidly,  as  the  other  symp- 
toms subside,  down  to  98°,  or  even  less.  When  the  relapse  occurs, 
about  the  fourteenth  day,  the  heat  again  increases  to  104°,  105°, 
or  more  ;  to  descend  as  rapidly  as  before,  when  convalescence 
begins. 

In  continued  fevers,  the  temperature  is  generally  less  high  in  the 
morning  than  in  the  evening.  In  typhus,  however,  not  unfre- 
quently  it  falls  a  little  towards  night. ^  Stability  of  temperature 
from  morning  to  evening  is  a  good  sign  ;  on  the  other  hand,  if  a 
high  temperature  remains  stable  from  evening  till  the  morning, 
it  is  a  sign  that  the  patient  is  getting  or  will  get  worse. 

When  the  temperature  begins  to  fall  from  the  evening  to  the 
morning,  it  is  a  sure  sign  of  improvement ;  but  a  rise  of  tempera- 
ture from  the  evening  till  the  morning  is  generally  a  sign  of 
getting  worse.  Inequalitij  of  temperature  in  different  parts  of  the 
body  is  sometimes  quite  important ;  especially  in  chronic  diseases 
of  the  nervous  system.  By  means  of  very  delicate  instruments, 
varying  temperatures  of  different  portions  of  the  head  (Broca, 
1877,  Lombard,  Bert,  Amidon,  L.  C.  Gray,  Mills)  have  been  noted 
in  some  cases.^  A  difference  has  been  observed  also  (Peter)  in 
regard  to  temperature,  between  peritonitis  with  effusion  and 
ascites  of  non-inflammatory  origin  ;  and  in  pleurisy,  when  the 
effusion  is  actively  increasing,  and  when  it  is  undergoing  absorp- 
tion ;  also  (Broca)  between  cerebral  embolism  (with  lessening  of 

1  Phila.  Med.  Times,  May  22,  1880,  p.  435. 

-  Observations  on  Relapsing  Fever,  by  Dr.  J.  S.  Parry,  Am.  Journ.  of  Medical  Sciences, 
October,  1870. 
3  J.  W.  Miller.  Brit,  and  Foreign  Medico-Cliirurg.  Review,  October,  1868. 
<  Phila.  Med.  Times,  March  13,  1S80,  p.  308. 


PNEUMATIC    A  S  P 1 11 A  T  I O  N  . 


133 


warinth  in  the  temporal  regions)  and  acute  cerebral  or  meningeal 
inflammation. 

Convalescence  from  disease  docs  not  begin  until  the  normal 
temperature  of  the  body  returns,  and  maintains  itself  unchanged 
through  all  periods  of  the  day  and  night. 

PNEUMATIC  ASPIRATION. 

Dr.  Bowditch,  many  years  ago,  commenced  the  use  of  a  fine 
"capillary"  trocar  and  canula,  which,  as  well  as  the  grooved 
needle  of  Trousseau,  have  now  long  been  in  common  use  for  the 
careful  exploration  of  any  of  the  cavities  of  the  body,  supposed  to 
contain  fluids.  Dr.  H.  P.  Walker,^  of  New  York,  proposed  the 
employment  of  the  hypodermic  syringe  for  the  same  purpose  in 
diagnosis.  M.  G.  Palletan,  in  1831,  devised  an  instrument  for  the 
same  object.  But  the  attention  of  the  profession  has  been  espe- 
cially given,  since  1859,  to  the  "pneumatic  aspirator"  of  Dr. 
Georges  Dieulafoy,  of  Paris.  By  tliis,  it  is  claimed,  the  greatest 
possible  safety  and  convenience  are  obtained  for  exploration  (and 
also  withdrawal  of  fluid)  in  pleuritic  and  pericardial  efiusions,  cysts 
in  various  regions,  abscesses  of  the  liver,  hjalrarthrosis,  retention 
of  urine,  strangulated  hernia,  etc.  Dr.  W.  Pepper  (1874)  has  em- 
ployed it  for  the  local  treatment  of  cavities  in  the  lungs  in  phthisis; 
and  Dr.  Howe,  of  New  York,  for  transfusion  of  blood.  The  spe- 
cial claim  of  Dr.  Dieulafoy,  besides  that  of  the  fineness  of  his  hol- 
low needles,  consists  in  the  use  of  the  "previous  vacuum,"  i.  e., 
a  chamber  in  his  instrument  exhausted 
of  air  before  the  introduction  of  the  hol- 
low needle  into  the  j)art  to  be  explored 
or  drained. 

The  application  of  the  instrument  is 
thus  described  :^ — 

"  The  aspirator  being  ready,  that  is  to 
say,  the  previous  vacuum  being  made, 
the  needle  is  introduced  sharply  at  the 
spot  pointed  out.  Before  the  needle  has 
penetrated  a  centimetre  into  the  tissue, 
that  is,  as  soon  as  its  opening  is  no  lon- 
ger in  contact  with  the  external  air,  the 
stopcock  connected  with  the  needle  is 
opened,  and  the  vacuum  is  thus  formed 
in  the  needle  itself.  This  needle,  carry- 
ing the  vacuum  with  it,  is  slowly,  very 
slowly,  pushed  in  the  direction  of  the 
bladder,  until  the  urine  flowing  over  the 
glass  index  shows  that  the  bladder  is 
pierced.  Owing  to  this  proceeding,  and 
having  the  previous  vacuum  at  our  com- 
mand, we  know  the  precise  moment  the 
fluid  is  reached." 

While  this  apparatus  and  method  appear  to  involve  a  real 


Fig.  74. 


Pneumatic  Aspirator  of 
Dieulafoy. 


1  See  T.  Gaillard  Thomas,  on  Diseases  of  Women.    Phila.  ed.,  1872,  p.  663. 
"Treatise  on  Pnoumatic  Aspiration,  etc.,  by  Dr.  G.  Dieulafoy.    Philada.  ed.,  1873. 
Tlie  instrument  has  been  improved  upon  by  I'otain,  Steurer,  and  others. 

12 


134  SEMEIOLOGY. 

improvement,  capable  of  great  utility  in  many  cases,  it  must 
not  be  supposed  that  their  employment  is  absolutely  with- 
out danger.  A  few  instances  of  fatal  result,  following  even 
the  introduction  of  the  hollow  needle  into  an  articulation,^  have 
enforced  the  necessity  of  caution  with  it.  Local  anaesthesia,  by 
Richardson's  spray-producer,  with  ether  or  rhigolene,  has  some- 
times been  employed  to  obviate  the  pain  caused  by  the  opera- 
tion. It  is  not  certain  whether  this  will  lessen  or  increase  the 
danger  of  subsequent  irritation. 

INSPECTION  OF  THE  BODY  AFTER  DEATH. 

In  conducting  post-mortem  examinations,  with  a  view  either  to 
pathological  study  or  medico-legal  investigation,  order  and  method 
are  of  great  importance. 

The  three  great  cavities — the  head,  the  chest,  and  the  abdomen 
— should  always  be  examined,  whether  suspicion  of  disease  in 
them  exists  or  not.  First,  however  (the  autopsy  being  made 
from  twelve  to  thirty-six  hours  after  death),  we  should  note  the 
external  appearance  of  the  body  ;  its  size,  weight,  conformation, 
color  of  the  slcin,  etc.  (In  cases  of  suspected  violence,  even  abra- 
sions should  be  minutely  described.) 

To  examine  the  Head,  an  incision  should  be  made  through  the 
scalp,  across  the  top  of  the  head,  from  ear  to  ear — the  two  flaps 
thus  formed  should  be  reflected,  the  one  over  the  forehead,  the 
other  over  the  occiput.  The  nature  of  the  attachment  of  the 
occipito-frontalis  muscle  to  the  bone  beneath  is  such  as  to  allow 
very  easily  the  loosening  of  the  scalp.  The  cranium  (calvaria)  is 
now  to  be  removed  by  means  of  a  small  saw. 

For  the  purpose  of  holding  the  head  firmly  during  the  use  of 
the  saw,. Dr.  T.  A.  Demme  has  furnished,  as  a  substitute  for  the 
craniotome  of  Lund,  of  London,  a  cranium-holder,  which  en- 
ables the  operator  to  make  a  section  of  the  skull  in  any  direction. 
It  consists  simply  of  a  bar  of  iron,  curved  like  the  letter  U,  at 
each  extremity  of  which  two  drill  screws  are  placed,  which, 
when  forced  down  upon  the  bone,  holds  the  bar  firmly  in  situ, 
and  enables  the  examiner  to  control  the  head.  The  legs  of  the 
instrument,  for  use,  are  placed  upon  the  lateral  portions  of  the 
skull,  over  the  squamous  portions  of  the  temporal  bones. 

The  section  of  the  cranium  with  the  saw  should  be  made 
through  its  outer  table,  completely  around  the  head— from  be- 
fore, oackward,  from  below  the  frontal  protuberances  to  the 
squamous  portion  of  the  temporal  bone,  and  from  behind  forward, 
from  the  occipital  protuberance  to  the  squamous  portion  of  the 
temporal  bone,  meeting  the  line  just  described.  The  shape  of 
the  piece  thus  cut  out  enables  it  to  be  maintained  in  its  proper 
position  when  the  parts  are  readjusted.  It  is  removed  by  the 
aid  of  an  elevator,  or  chisel  and  hammer,  fracturing  the  inner 
table  of  the  skull  by  strokes  so  applied  as  not  to  i)ierce  the 
brain. 

The  dura  mater  is  next  to  be  cut  through,  on  each  side  of  the 
superior  longitudinal  sinus;  after  which,  dividing  the  falx  cerebri, 

1  See  Irish  Hospital  Gazette,  Jan,  15, 1873. 


POST-MORTEM     EXAMINATIONS.  135 

the  brain  may  be  raised  carefully  with  the  hand  placed  under  its 
anterior  portion.  The  internal  carotid  artery,  and  cranial  nerves, 
etc.,  are  now  to  be  severed  by  tlie  knife,  and  finally,  the  vertebral 
arteries  and  spinal  cord.  Tlie  brain  itself  may  then  be  taken 
out  and  inspected,  by  slicin<^  it  from  the  upper  part  downward, 
in  successive  horizontal  layers.  Both  before  and  after  its  re- 
moval, the  amount  of  Uqu'ul  present  should  be  carefully  noted  ; 
measuring  it,  if  excessive,  by  the  aid  of  a  pipette  or  small  syr- 
inge and  graduated  glass.  Instead  of  horizontal,  many  pathol- 
ogists prefer  oblique  (vertico-transverse)  or  longitudinal  vertical 
sections  through  the  hemispheres,  on  each  side  of  the  great  lon- 
gitudinal fissure.  Modern  neurologists  insist  much  on  the  ex- 
amination of  the  "psycho-motor  "  and  "  psycho-sensory"  zones. 
(See  Part  I.,  Neuropathology),  as  well  as  the  thalamic  corpora  stri- 
ata, and  internal  and  external  copsufe.s.  There  seems  to  be  patho- 
logical importance  in  distinguishing,  in  what  was  formerly  de- 
scribed en  masse  as  the  corpus  striatum,  two  parts  ;  the  anterior, 
intraventricular  portion,  the  nucleus  caudatus;  and  posteriorly, 
the  extra-ventricular  portion,  nucleus  lenticulatus.  Between  the 
caudate  nucleus  and  thalamus  above,  and  the  lenticular  nucleus 
below  and  without,  is  the  internal  capsule,  of  white  fibrous  ner- 
vous matter  ;  a  portion  of  the  cms  cerebri.  Outside  of  the  len- 
ticular nucleus  is  the  white  fibrous  external  capsuled 

To  examine  the  Spinal  Colunm,  an  incision  should  be  made 
from  the  occipital  protuberance  to  the  extremity  of  the  os 
coccygis.  The  deep  muscles  of  the  back  should  then  be  loosened 
from  their  attachments,  so  as  to  expose  the  laminse  and  spinous 
processes  of  all  the  vertebrae.  With  the  chisel  and  mallet,  or 
saw,  we  must  cut  through  the  arches  of  the  vertebrae  on  each 
side,  close  to  their  articular  processes.^  After  thus  opening  the 
spinal  canal,  the  cord  is  to  be  exposed  by  dividing  the  dtira  mater 
through  its  whole  length. 

To  examine  the  Neck,  an  incision  should  be  made  through  the 
skin,  extending  from  above  the  hyoid  bone  to  the  upper  part  of 
the  sternum.  Avoiding  penetration  of  the  large  veins  of  the 
neck,  the  parts  to  be  examined  may  be  carefully  dissected,  and 
if  desirable,  removed  from  the  body.  The  thyroid  gland,  larynx, 
and  its  appendages,  tongue,  pharynx,  oesophagus,  blood-vessels, 
and  nerves  of  the  neck,  may  be  thus  viewed. 

To  examine  the  Chest,  two  incisions  are  desirable ;  the  one 
from  the  root  of  the  neck,  in  front,  to  the  extremity  of  the  ensi- 
form  cartilage  ;  the  other  at  right  angles  to  this,  across  the  mid- 
dle of  the  thorax.  The  cartilages  of  the  ribs  are  to  be  cut 
through,  with  a  strong  knife,  at  the  lines  of  junction  with  the 
ribs.  The  ensiform  cartilage,  being  drawn  outward,  is  to  be  de- 
tached from  the  soft  parts,  the  knife  being  held  close  to  the  sternum. 

1  An  interesting  subject  for  minute  investigation  is  the  question  whether  the  fibres 
of  the  internal  capsule  constitute  a  direct  continuous  connection  between  the  cortex  of  the 
cerebrum  and  the  spinal  cord, — or  communicate  only  by  means  of  the  ganglionic  masses 
at  the  base  of  the  brain.  Pathological  evidence  favors  the  former  answer  to  this  ques- 
tion; but  physiological'analogy  is  against  it,  and  I  am  not  aware  that  it  has  yet  (1881) 
been  positively  settled  by  anatomical  deiuonstration. 

-  Dr.  Satterthwaite's  modification  of  Brunett's  chisel  has  great  convenience  for  ex- 
posing the  spinal  canal.    See  N.  Y.  Med.  Record,  May  8, 1880,  p.  520. 


136  SEMETOLOGY. 

The  stemo-clavicular  articulation  may  now  be  opened,  and  the 
sternum  with  the  costal  cartilages  raised  from  its  position — a 
cautious  use  of  the  knife  being  made  to  remove  the  adherent 
soft  parts. 

The  thoracic  viscera  are  now  exposed,  and  may  be  drawn  out 
with  care,  and  inspected  in  detail. 

The  heart  should  be  removed  first,  after  opening  the  pericar- 
dium by  a  vertical  incision,  and  ascertaining  the  presence  or 
absence  of  adhesions,  effused  fluid,  etc.  The  apex  is  then  to  be 
raised,  and  the  great  vessels  at  the  "  root  "  of  the  heart  divided 
at  a  short  distance  from  its  base.  Laying  the  heart  upon  a 
board,  as  nearly  as  possible  in  the  position  it  occupies  in  a  recum- 
bent body,  the  auricles  and  ventricles  may  be  carefully  laid 
open. 

The  right  auricle  may  be  opened  by  cutting  through  its  middle 
portion,  betwen  the  entrances  of  the  vence  cavce.  The  left  auricle 
may  be  entered  by  an  incision  commencing  near  the  left  superior 
pulmonary  vein. 

The  right  ventricle  should  be  laid  open  by  a  deep  incision  from 
the  base  to  the  apex,  beginning  near  the  septtim  at  the  base. 
The  left  ventricle  is  to  be  opened  by  a  similar  deep  incision  from 
the  base  to  a  point  not  far  from  the  apex. 

Especial  care  is  needed  in  dividing  the  parts  near  the  orifices 
of  the  aorta  and  pulmonary  artery,  so  as  to  examine  the  condition 
of  their  valves.  Scissors  are  convenient  for  this  part  of  the 
inspection.  In  examining  the  mitral  and  tricuspid  valves,  care 
must  be  taken  not  to  confuse  appearances  by  a  promiscuous 
division  of  the  membranous  ct^sps,  as  well  as  of  the  columnce 
carnece  and  char  dee  tendinece. 

The  lungs  may  be  placed  first  in  water  to  determine  whether 
they  will  float  or  not  (the  lungs  of  a  still-born  infant,  which  has 
never  breathed,  will,  unless  from  some  extraordinary  cause,  sink 
in  water).  The  same  may  be  done  with  portions  of  the  lungs 
after  they  have  been  cut  for  examination.  Incisions  for  this 
purpose  should  be  made,  vertically  and  transversely,  through"^ 
each  pulmonary  lobe.  The  bronchial  tubes  may  be  best  divided 
with  long-bladed  scissors,  cutting  towards  the  lungs. 

To  examine  the  Abdomen,  make  a  crucial  incision  ;  the  one 
branch  extending  from  the  sternum  to  the  pubes,  passing  to  the 
left  of  the  umbilicus  ;  the  other  transversely  across  the  middle 
of  the  abdomen.  Care  must  be  taken,  in  making  these  incisions, 
not  to  injure  the  subjacent  viscera. 

Before  removing  the  stomach  or  any  portion  of  the  intestines, 
ligatures  should  be  placed  above  and  below  the  part  that  is  to  be 
separated. 

When — as  is  always  desirable,  if  possible — both  of  the  large 
cavities  of  the  trunk  are  to  be  opened,  a  single  incision,  extend- 
ing from  the  top  of  the  sternum  to  the  symphysis  pubis,  may  be 
made. 

The  weight  of  organs,  altered  by  disease,  is  sometimes  an  im- 
portant point.  The  following  are  normal  weights  of  the  prin- 
cipal organs  in  healthy  adult  subjects  : 


MEDICO-LEGAL    EXAMINATIONS, 


137 


Male. 

Female. 

49J  oz. 

44  oz. 

.    1  oz.  4  dr. 

1  oz.  4  dr. 

[  right,  24  oz. 
•.       (left,     21  " 

17  oz. 

15  " 

.       11    oz. 

9  " 

.       63    " 

45  " 

6     " 

5  « 

.        .         5i  " 

5  " 

. 

.   1  to  U  dr. 

Brain 
Spiual  cord 

Lungs 

Heart 

Liver 
Spleen 
Kidney 
Ovary 

In  every  case  incision  through  the  skin  should  be  made,  as  far 
as  practicable,  only  in  those  parts  which  are  usually  covered  by 
the  clothes  of  the  deceased.  It  is  generally  advisable,  when  the 
abdomen  or  thorax  has  been  opened,  to  fill  the  cavities  with  bran 
or  sawdust.  After  the  examination  has  been  completed,  the  edges 
of  the  divided  integument  should  be  brought  together,  and  re- 
tained in  apposition  by  the  common  continued  suture.^ 


MEDICO-LEGAL  EXAMINATIONS. 

In  cases  of  suspected  poisoning,  the  following  practical  direc- 
tions are  given  by  Professor  Reese,  of  the  University  of  Pennsyl- 
vania, to  be  observed  by  those  who  have  charge  of  post-nwrtem 
examinations : 

1.  Ascertain  whether  the  individual  has  labored  under  any 
previous  illness,  and  how  long  a  time  had  elapsed  between  the 
first  suspicious  symptoms  and  his  death  ;  also  the  time  that  had 
elapsed  after  death  before  the  inspection  is  made. 

2.  Note  all  the  circumstances  leading  to  a  suspicion  of  murder 
or  suicide,  such  as  the  position  and  general  appearance  of  the 
body,  and  the  presence  of  bottles  or  papers  containing  poison 
about  his  person  or  in  the  room. 

8.  Collect  any  vomited  matters,  especially  those  first  ejected, 
and  preserve  them  in  a  clean  glass  jar,  carefully  stoppered  and 
labelled.  The  vessel  in  which  the  vomited  matters  have  been 
contained  should  be  carefully  inspected  for  any  solid  (mineral) 
matters  which  may  have  sunk  to  the  bottom  or  adhered  to  the 
sides.  If  no  vomited  matters  be  procurable,  and  vomiting  has 
taken  place  on  the  dress,  bedclothes,  furniture,  etc.,  then  portions 
of  these  must  be  carefully  preserved  for  future  examination, 

4.  Before  removing  the  stomach,  apply  two  ligatures  beyond 


1  The  examiner  should  wash  his  hands  with  the  utmost  thoroughness  after  an 
autopsy,  for  his  own  sake  as  well  as  that  of  others,  especially  patients  to  be  visited. 
If  the  subject  examined  died  of  a  disease  capable  of  contagion  or  infection  (in  which 
category  erysipelas,  puerperal  fever,  and  diphtheria  must  be  included)  some  disinfectant 
should  be  used.  I  prefer  Labarraque's  solution  of  chlorinated  soda  for  this  purpose.  A 
fluidounce  of  it  may  be  poured  slowly  over  the  hands  above  a  basin  of  warm  (or  hot) 
water,  in  which  they  should  then  be  washed.  If  this  is  followed  by  a  vigorous  scouring 
with  castile  soap  and  water,  very  little  danger  of  conveying  disease  will  remain.  An 
abrasion  upon  any  part  of  the  hand  should  forbid  its  being  used  in  an  autopsy,  or,  at 
least,  being  brought  in  contact  with  the  internal  cavities  of  organs.  If  a  puncture  or 
incision  of  the  examiner's  hand  occur  during  the  operation,  the  proper  thing  (however 
disagreeable)  is  to  wash  and  suck  it  immediately,  and  then  keep  it  out  of  all  contact 
Willi  the  body.    Not  a  few  lives  have  been  sacrificed  by  neglect  of  these  precautions. 


12* 


138  GENERAL.    THERAPEUTICS. 

each  extremity,  dividing  between  each  pair,  so  as  to  prevent  the 
loss  of  any  of  the  contents. 

5.  If  the  stomach  be  opened  for  inspection,  this  should  be  per- 
formed in  a  perfectly  clean  dish,  and  the  contents  collected  care- 
fully in  a  graduated  vessel,  so  as  to  properly  estimate  their  quan- 
tity. [I^ote  here,  also,  the  presence  of  blood,  mucus,  bile,  or 
undigested  food.]  These  contents  should  be  preserved  in  a  per- 
fectly clean  glass  jar,  securely  stoppered,  covered  over  with  blad- 
der, and  sealed.  The  contents  of  the  duodenum  should  be  collected 
and  preserved  separately. 

6.  Carefully  inspect  the  state  of  the  throat,  oesopJiagiis,  and 
windpipe  for  the  presence  of  foreign  substances,  and  for  marks 
of  inflammation  or  corrosion. 

7.  Observe  the  condition  of  the  large  intestine,  especially  the 
rectum:  the  presence  of  hardened  feces  would  indicate  that 
purging  had  not  very  recently  taken  place. 

8.  Note  any  morbid  changes  in  the  lunys,  as  congestion,  inflam- 
mation, or  eflusion  ;  in  the  heart,  as  contraction,  flaccidity,  pres- 
ence of  a  clot ;  and  the  condition  of  the  contained  blood. 

9.  Examine  the  state  of  the  brain  and  spinal  marrow,  and,  in 
the  female,  the  condition  of  the  uterus,  ovaries,  and  genital  organs. 
[Poisons  have  sometimes  been  introduced  into  the  vagina.] 

10.  Along  with  the  contents  of  the  stomach  and  duodenum, 
the  viscera  that  are  to  be  reserved  for  chemical  analysis  are  tlie 
stomach  and  duodenum  (to  be  kept  separate  from  the  others), 
the  liver  and  gall-bladder,  spleen,  kidney,  rectum,  and  urinary 
bladder  with  its  contents.  Sometimes,  also,  a  portion  of  the 
hlood  may  be  required  for  the  examination. 

11.  As  the  legal  authorities  wiU  rigorously  insist  upon  proof 
of  the  identity  of  the  matters  alleged  to  be  poisonous,  it  is  of  the 
greatest  importance  to  preserve  such  matters  from  all  possible 
contamination  by  incautious  contact  with  a  surface  or  vessel 
which  is  not  absolutely  clean.  Avoid  the  use  of  colored  calico  or 
paper  for  wrapping  up  the  specimens.  When  once  the  suspected 
articles  are  deposited  in  the  hands  of  a  medical  man,  he  must 
preserve  them  strictly  under  lock  and  key,  and  confide  them  only 
to  a  trusty  agent  for  transportation.  Many  cases  are  on  record 
where  the  chemical  evidence  failed  simply  from  a  want  of  power 
clearly  to  establish  the  identity  of  the  matters  analyzed. 

Actual  testing  for  poisons  in  cases  of  suspected  criminality 
ought  to  be  undertaken  only  by  those  whose  chemical  knowledge 
and  skill  are  considerable. 


SECTION  m. 

GENERAL  THERAPEUTICS. 

Eemedies  have  been  classified,  for  the  study  of  Materia  Medica, 
in  a  manner  which  is  sufficiently  well  adapted  to  the  present  state 
of  that  science. 

I  propose  the  following  classification,  from  the  standpoint  of 


GENERAL    THERAPEUTICS.  139 

the  practitioner,  i.  e.,  according  to  the  indications  of  treatment, 

or  objects  proposed. 

Thus  regarded,  remedies  may  be  studied  as — 

Anodyne  and  calmative;  e.  y.,  opium;  ether;  chloroform;  aco- 
nite ;  Ijydrocyauic  acid  ;  hydrate  of  chloral. 

Protective;  e.  {/.,  demulcents;  surgical  dressings. 

Balancive ;  c.  y.,  cold  to  an  over- vascular  part ;  pediluvia ;  blood- 
letting. 

Economic ;  rest;  astringents ;  retarders  of  tissue-metamorphosis. 

Eliminative;  e.  y.,  purgatives;  iodide  of  potassium,  etc. 

Antidotive;  e.  y.,  liydr.  ox.  of  iron  for  arsenical  poisoning;  ant- 
acids; cinchonization  in  intermittent. 

Alterative;  e.  r/.,  nitrate  of  silver  in  scarlatinal  sore  throat  ; 
arsenic  in  skin  diseases  ;  electricity  in  cancer,  etc. 

Recuperative ;  stimulants  ;  tonics  ;  chalybeates  ;  oleum  mor- 
rhute  ;  travelling. 

An  elaborate  work  might,  of  course,  be  written  upon  the  topics 
just  enumerated.  It  is  appropriate  to  our  purpose,  only  to  state 
them ;  dwelling,  presently,  upon  another  yet  more  brief  classifi- 
cation, of  the  modes  of  treatment  7nost  freqicently  called  for,  in  the 
management  especially  of  acute  and  subacute  aftections. 

First,  a  few  words  upon  balancive  measures.  These  constitute 
a  very  large  part  of  therapeutics  ;  one  of  the  most  constant  ele- 
ments of  disease,  and  especially  of  acute  diseases,  being  a  dis- 
turbance of  the  proptortion  of  circulation,  nutrition,  innervation, 
and  action  in  diflerent  parts. 

For  example:  when  one  "takes  cold,"  what  has  occurred? 
Chilling  the  surflxce,  as  by  damp  air,  has  checked  perspiration, 
contracted  the  superficial  blood-vessels,  causing  congestion  of  inte- 
rior organs,  and  partial  contamination  of  the  blood,  from  retained 
excretory  matter.  What,  then,  is  the  "indication"  or  pointing  of 
nature  ? 

Clearly,  it  is  to  restore  the  lost  balance  ;  by  warmth  to  bring  on 
perspiration  (unless  fever  occurring  demand  another  method); 
purgatives  and  diuretics,  with  plenty  of  water,  to  relieve  the  blood 
of  its  morbid  excess  of  excreta. 

Again,  in  flatulent  colic,  unequal  distension  and  spasmodic 
contraction  of  a  bowel  occur,  from  gaseous  accumulation  or  the 
presence  of  irritating  ingesta.  Aromatics,  such  as  ginger  ;  stim- 
ulants, as  hot  water  or  whisky ;  or  anodynes,  as  camphor  or 
opium,  by  a  diffusive  action  on  the  whole  surface  of  the  affected 
intestine,  and  upon  its  innervation  when  they  are  absorbed  and 
reach  the  gangUa,  will  renew  a  proportionate  contraction  (peri- 
staltic) of  the  muscular  coat,  and  remove  the  pain,  Yery  often, 
gentle  friction,  pressure  or  kneading  the  abdomen,  or  external 
warmth  all  over  it,  will  have  a  similar  balancive  eftect. 

Laxatives  for  deficient  movement  of  the  bowels,  astringents 
for  excess  of  the  same  ;  cold  to  a  too  hot  head,  and  mustard  and 
hot  water  to  cold  feet,  are  all  balancive  means.  So  is  the  familiar 
and  always  safe  use  of  n  mustard-plaster  to  the  skin,  over  any  part 
of  body  which  suffers  pain.  Pain  denotes  a  morbid  innervation 
from  some  cause.  Apply  something  which,  like  mustard,  causes 
a  strong  impression  in  a  dilferent  place,  not  too  remote,  and  tlie 


140  GENERAL    THERAPEUTICS. 

"eiTor  loci"  of  nerve-tension  (or  debilitation,^  as  the  case  may  fee), 
is  done  away  witli — the  balance  is  restored. 

Notice  may  be  here  taken,  briefly,  of  a  "method"  in  thera- 
peutics, extending  the  balancive  principle  systematically — called 
the  "neuropathy"  [gangliotlierapy)  of  Dr.  John  Chapman. 

The  origin  of  this  is  really  to  be  credited  to  the  vivisections  of 
Bernard  and  Brown-Sequard,'^  and  conclusions  based  upon  them, 
especially  by  the  latter.  The  experiment  of  most  importance  in 
this  connection  has  been  the  section  of  the  sympathetic  nerve  in 
the  neck  of  a  rabbit ;  which  was  found  to  be  followed  by  dilatation 
of  the  blood-vessels  of  its  ear.  It  was  concluded  from  this  and 
other  facts  similarly  obtained  (all  traumatic  or  pathological,  as, 
indeed,  are  all  facts  of  vivisection),  that  to  increase  the  amount  of 
blood  and  sensibility  in  any  part  of  the  body,  you  must  paralyze, 
partially  or  temporarily,  its  sympathetic  ganglion.  To  diminish 
its  vascularity  and  sensibility — you  should  excite  its  vasomotor 
nerve-centre. 

Dr.  John  Chapman  systematized  the  use  of  these  principles,  by 
the  application  of  elastic  bags,  containing  ice,  or  hot  water,  along 
the  spine  ;  so  as  to  act  upon  the  ganglia  located  thereupon,  and, 
through  them,  to  aflfect  the  viscera,  both  palliatively  and  cura- 
tively,  in  disease.  "He  considers  that  ice  applied  along  the  spine 
increases  the  general  circulation,  stops  the  cramp  of  voluntary 
and  involuntary  muscles,  proves  an  effective  remedy  in  epilepsy 
and  other  convulsive  affections,  cures  sea-sickness,  restrains  the 
sickness  of  pregnancy,  arrests  diarrhcea,  recovers  patients  from 
the  cold  stage  of  cholera,  and,  finally,  promotes  menstruation. 
On  the  other  hand,  heat  along  the  spine  lessens  the  general 
circulation,  overcomes  congestion  in  all  parts  of  the  body,  lessens 
fever,  restrains  hemorrhage,  and  lessens  or  arrests  the  menstrual 
flow." 

If  the.  phiisiological  theory  of  Brown-S^quard,  above  mentioned, 
were  true,  the  therapeutical  process  of  Chapman,  deduced  from  it, 
might  be  justified.  I  deny  the  truth  of  the  one,  and,  a  pjriori, 
have  no  belief  in  the  validity  of  the  other.  Clinical  experience, 
however,  must  decide  the  claims  of  the  practice. 

It  must  be  remembered,  that  a  pjractice  may  prove  beneficial, 
whether  the  theory  which  suggested  it  be  correct  or  not.  Hot  and 
cold  applications  to  the  spine  must  make  (especially  when  alter- 
nated, as  Brown-Sequard  proposed  for  bed-sores)  a  strong  impres- 
sion on  the  whole  system ;  this  may  prove  a  rapidly  alterative 
impression  in  certain  cases  of  disease.  Should  this  prove  so,  the 
use  of  such  means  should  be  adopted,  just  as,  and  so  far  as,  ex- 
perience shows  it  to  be  useful.  JSTo  such  utility  of  applications 
whose  explanation  may  be  reached  in  many  different  ways,  can 
make  the  theory  above  cited  seem,  to  the  present  writer,  other 
than  erroneous. 

The  modes  of  treatment  most  frequently  called  for,  in  ordinary 
medical  practice,  may  be  designated  as — 

1  RadclifFe  "  On  Epilepsy,  Pain,  and  Paralysis ; "  Inman,  op.  citat. 

2  See  his  Lectures  on  the  Nervous  System,  p.  205,  etc.  See,  also,  a  discussion  of  the 
experiment  mentioned,  in  the  author's  Prize  Essay  on  the  Arterial  Circulation.. 


GENERAL    THERAPEUTICS.  141 

The  antiphlogistic ;  The  supporting ; 

The  febrifuge ;  The  antidotive  ; 

The  alterative  treatment. 

Under  the  first  head,  the  antiphlogistic '  {i.  e.  the  treatment  of 
inflammation),  we  place — 

Rest ;  position;  Tartar  emetic ;  Digitahs; 

Cold  applications  ;      Nitrate  of  potassium ;  Ergot ; 
Venesection ;  Ipecacuanha ;  Mercury ; 

Local  depletion  ;         Veratrum  viride  ;  Opium  ; 

Purgation  ;  Diet ;       Aconite  ;  Counter-irritation. 

The  necessity  of  rest  during  active  inflammation  of  any  organ  is 
a  rule  without  exception. 

A  choice  of  position  is  often  dictated  by  the  sensations  of  the 
patient.  AVhen  one  of  the  extremities  is  inflamed  its  elevation  is 
advised,  in  order  to  allow  the  blood  to  return  from  the  overloaded 
vessels. 

Cold  applications  are  very  important  in  the  treatment  not 
only  of  inflammation,  but  of  active  hypermmia  or  congestion  (e.  </., 
"determination  of  blood"  to  the  liead).  The  two  precautions 
most  necessary  in  their  use  are,  that  the  cold  be  sustained,  but 
not  excessive,  and  that  it  be  not  ill-timed,  so  as  to  arrest  desirable 
perspiration.  The  employment  of  cold  applications  has  been  very 
boldly  extended  by  some  practitioners,  even  to  such  affections  as 
pneumonia,  pericarditis,  etc.  In  such  cases,  it  must  require  great 
care  and  judgment  not  to  do  harm  instead  of  good.  I  am  afraid 
of  such  experiments.^ 

For  continued  local  refrigeration,  Knowsley  Thornton's  "ice- 
cap" is  very  convenient.  It  is  a  coil  of  small  India-rubber  tubing, 
through  which  ice-water  is  made  to  flow  constantly. 

Kibbee's  "fever-cot"  may  be  used  for  either  partial  or  general 
cooling  of  the  body.  It  consists  of  a  folding  cot  (such  as  is  com- 
monly" made  use  of  as  a  temporary  bed)  with  strong  elastic  cotton 
netting  stretched  across  it  instead  of  canvas.  Under  this,  to  the 
whole  length  and  breadth  of  the  bed,  hangs  a  piece  of  India-rubber 
cloth.  A  blanket  being  laid  upon  the  cotton  netting,  the  patient 
is  placed  thereupon,  and  covered  with  a  sheet  or  another  blanket. 
When  water  is  poured  over  the  body,  it  runs  through  the  netting 
and  is  carried  off  by  the  gutter  formed  by  the  India-rubber  cloth 
below.  If  refrigeration  of  the  abdomen  only  is  wanted  (as  after 
ovariotomy),  the  upper  part  of  the  body  is  protected  from  the 
irrigation,  and  bottles  of  warm  water  are  placed  in  contact  with 
the  feet.  Dr.  Noeggerath  prefers  a  water-bed  of  India-rubber 
(covered  with  a  blanket)  upon  which  the  patient  lies;  water  at 
the  desired  temperature,  cold  or  warm  according  to  the  case, 
being  injected  at  will. 

1  Some  writers  pronounce  the  whole  idea  of  antiphlogistic  treatment  to  he  obsolete. 
Its  judicious  use  is  likely,  nevertheless,  to  survive  the  generation  in  which  this  opinion 
has  been  formed  and  expressed. 

21  have,  however,  known  two  patients  with  acute  pneumonia  (one  of  them  a  lady 
Dver  eighty  years  of  age)  to  crave  cold  air  to  breathe;  begging  to  have  the  windows  wide 
open,  although  the  temperature  was  bolow  freezing.  Both  recovered  ;  showing  that  no 
harm  was  done  by  this  indulgence,  their  bodies  being  well  protected  from  exposure  to 
the  cold.    Dr.  J.  T.  Jiverett  has  cured  cases  by  continuous  inhalation  of  cold  air. 


142  GENERAL,    THERAPEUTICS. 

Bloodletting,  by  venesection,  leeching,  and  cupping,  is  one  of  the 
oldest,  and  has  been  one  of  the  most  universal  of  remedies  for 
inflammation.  Although  "'d;^o^w/?oi,"  or  ''blood-fearers,"  have 
appeared  in  all  ages  and  nations,  yet  the  aggregate  testimony 
of  the  profession,  from  Hippocrates  down  almost  to  the  present 
time,  has  been  in  favor  of  the  use  of  the  lancet  and  of  local  blood- 
letting in  the  treatment  of  violent  inflammations  and  congestions. 

Now,  however,  it  must  be  admitted  that  bloodletting  has  more 
opponents  and  fewer  defenders  than  at  any  previous  period  in 
medical  history.    Why  is  this  ?    By  reason  of— 

1.  Reaction  from  previously  existing  abuse  of  the  remedy. 

2.  A  change  in  average  human  constitution,  occurring  under  the 
artificial  habits  of  civilized  life. 

3.  False  construction  and  misapplication  of  recent  science. 

4.  Leadership  und  fashion. 

I  must  briefly  remark,  that  the  reaction  alluded  to  has  proceeded 
too  far,  going  from  one  extreme  to  another. 

The  change  occurring  especially  in  large  cities,  in  the  average 
human  constitution,  aftords  good  reason  for  limiting  the  use  of  the 
lancet  to  a  smaller  number  of  cases  than  was  once  thought  neces- 
sary; and  for  using  especial  caution  as  to  the  amount  of  blood 
abstracted;  but  not  for  abandoning  the  remedy  altogether. 

The  improved  condition  of  the  sciences  of  semeiology  and 
pathology  gives  us  the  power  to  discriminate  more  narrojvdy  in  our 
use  of  bloodletting,  as  well  as  of  other  remedies.  But  we  should 
not,  for  this,  throw  aside  as  useless  all  the  experience  of  our  pre- 
decessors ;  as  if  every  new  fact  was  necessarily  the  heir  of  some 
dead  old  one.     All  facts,  old  and  new,  should  be  retained. 

In  the  physiological  and  pathological  science  which  bears  upon 
the  question,  I  hold  that  false  construction  and  misapplication  of 
observed  facts  have  been, operative.  An  important  threefold  error 
has  been  committed,  viz. : — 

1.  In  physiology,  the  denial  or  depreciation  of  the  active  part 
taken  by  the  arteries  in  the  circulation ;  and  of  the  great  fact, 
without  recognition  of  which  no  theory  of  inflammation  can  stand, 
that  the  arteries  are  subject  to  reflex  excitement — the  most  normal 
form  of  which  constitutes  active  hypersemia,  the  most  abnormal 
and  exceptional,  tonic  constriction  of  the  vessels. 

2.  The  error  of  Prof.  J.  H.  Bennett,  of  giving  attention,  in 
regard  to  the  pathology  of  the  inflammatory  process,  to  the  exuda- 
tion alone. 

3.  That  of  Prof.  Yirchow,  in  considering  that  no  important 
difference  in  kmd  exists  between  morbid  lesions  of  nutrition  in 
vascular  and  in  non-vascular  tissues  ;  and  that  stimulation,  irri^ 
tation,  and  inflammation  are  essentially  and  practically,  as  well  as 
chronologically,  only  degrees  of  the  same  vital  impression. 

The  theory  of  inflammation  which  has  been  already  laid  down,^ 
as  entirely  consistent  with  the  observations  (whatever  may  have 
been  the  reasonings)  of  the  most  accurate  pathologists  (e.  g., 
Bokitansky,  Paget,  Wharton  Jones),  inculcates,  that  the  de- 
termination of  blood  towards  an  inflamed  part  conspires  with  the 

1  See  General  PatMogy,  Part  I.,  Section  III. 


BLOODLETTING.  143 

central  stasis  in  causing  the  exudation  ;  and  that  a  constant  jiro- 
poriion  exists  between  the  do/rcc  of  this  active  turgescence  and 
the  amount  of  the  exudation,  and  the  character  of  the  changes  which 
it  subsequently  undcrjioes. 

Now,  of  the  cardinal  elements  of  the  inflammatory  process,  the 
local  arrest  of  nutrition,  and  capillary  stasis  cannot  be  directly 
affected  by  treatment.  Nor,  when  the  exudation  lias  occurred^  can 
any  but  ])alUative  or  exjiectant  measures  1)e  applied  to  the  manage- 
ment of  its  changes.  But,  the  active  concentric  determination 
of  blood — the  arterial  excitement — cannot  this  be  essentially  modified 
by  treatment  f   Yes. 

By  abstraction  of  blood,  we  lessen  (for  a  time  at  least) — 

1.  The  fulness  of  the  vessels  ; 

2.  The  number  of  red  corpuscles ; 

3.  The  force  of  the  heart's  impulse  ; 

4.  The  force  of  the  arterial  impulse  ; 

5.  The  excitement  of  nerve-centres. 

And  by  each  and  all  of  these  influences,  we  diminish  the  vas- 
cular excitement  connected  with  an  inflammation ;  and  thus  (I 
repeat)  lessen  the  amount  of  the  resultant  exudation,  and  (Paget) 
render  its  "■biography"  more  normal,  its  changes  less  degenerative 
and  destructive.'  Reference  has  been  made,  on  a  previous  page, 
to  the  ftxcts  reported,  by  Drs.  Onderdonk,  Rogers,  H.  F.  Camp- 
bell, Maunder,  Moore,  Vanzetti,  Blackman,  S.  W.  Gross,  II.  H. 
Mudd,-  and  others,  showing  the  important  effect  of  cutting  ofli" 
the  arterial  supply  of  an  inflamed  part,  in  subduing  inflammation. 

If  this  be  true,  it  is  altogether  an  erroneous  assumption  of 
Prof.  Bennett  that  inflammation  is  a  "self-limited  process  which 
cannot  be  cut  short  nor  interfered  with  to  advantage."  If  there 
be  anything  positive  in  medical  experience,  I  believe  the  contrary 
of  this  to  have  been  established. 

1  It  may  be  hoped  that  the  time  has  gone  by  when  any  question  in  therapeutics  can 
be  decided  by  leadership.  But  the  "bloodletting  controversy"  has  shown,  that  the 
medical  mind  is  not  yet  absolulely  free  from  its  influence.  As  to  authorities,  old  and 
new,  it  may  interest  the  student  to  remember,  that  of  ancient  opponents  to  the  lancet, 
Chrysippus  and  Erasistratus  were  the  most  noted;  of  the  modern  European  schools, 
Van  Helmont,  Dietl,  and  Skoda,  in  Germany ;  Huss,  in  Sweden  ;  Bennett  aud  Todd,  in 
Great  Britain.  Exemplification  of  Sangrado's  practice,  on  the  contrary,  has  been 
especially  accredited  to  CuUen,  in  England  ;  Rasori,  in  Italy ;  Chomel  aud  Bouillaud,  in 
France;  aud  Rush  (the  father  of  American  medicine),  in  this  country.  We  should 
place  in  the  class  of  moderate  bleeders  of  antiquity,  Hippocrates,  Asclepiadcs,  Celsus, 
Galen,  Avicenna,  and  "6i  TraKXot;"  of  earlier  English  and  i'^rench  teachers,  Sydenham, 
Huxhara,  Gregory.  Lacnnee,  etc. ;  of  the  present  date,  the  late  Professor  Alison,  with 
Watson,  Christison,  Copeland,  Lawrence,  Chambers,  Parkes,  C.West,  Gairdner,  Symonds, 
F.  Winslow,  Aitken,  Markhara,  Haiidfield  Jones,  Dyce  of  Aberdeen,  Sutton,  Geo. 
Johnson,  B.  W.  Ricliardson,  aud  others,  in  Great  Britain  ;  Wunderlich,  Oppolzer, 
Graefe,  and  Kicnieyer,  in  Germany;  Jaccoud,  Herard,  and  Cornil,  iu  France;  and,  in 
this  country,  G.  B.  Wood,  S.  D.  Gross,  Austin  Flint,  II.  J.  Bowditch,  J.  F.  Meigs,  A. 
Clark,  Fordyce  Barker,  W.  Pepper,  and  others.  As  slalisUcs  have  been  especially 
appealed  to  by  the  opponents  of  bloodletting,  it  may  be  proper  to  quote  here,  the 
conclusion  of  an  able  analysis  of  much  of  the  evidence  of  this  kind  made  public  (Brit, 
and  For.  Medico-Chirurg.  Rev.,  July,  1858).    It  is  as  follows: — 

"  While  the  non-bleeding  plan  (in  pneumonia)  has  a  demonstrable  advantage  over 
that  of  indiscriminate  and  repeated  bleedings,  we  maintain  that  the  discriminating 
practice  of  moderate  and  early  bleeding,  general  or  local,  in  cases  of  more  or  less  sthenic 
inflammation,  and  of  refraining  from  it  altogether  in  asthenic  cases,  whether  as  regards 
the  character  of  the  disease  or  the  constitution  of  the  patient,  impressed  upon  us  both  by 
experience  and  science." 

»St.  Louis  Courier  of  Medicine,  April,  188L 


144  GENERAIi    THERAPEUTICS. 

Thus  much,  perhaps,  may  be  allowed  to  the  influence  of  recent 
ratiocinations  and  experimentations  in  medical  practice  without 
the  lancet :  that  local  bloodletting  may  be  admitted,  in  many 
instances,  to  have  all  the  advantages  which  can  be  claimed  for 
venesection,  except  convenience;  and  that,  in  doubtful  cases,  the 
smaller  quantity  abstracted  ought  always  to  be  an  argument  in 
favor  of  local  rather  than  general  depletion.  This  admission  may 
be  made  without  surrendering,  in  the  least  degree,  the  principle 
of  therapeutics  upon  which  bloodletting  is  scientifically  justified, 
and  according  to  which,  if  we  are  to  interfere  at  all  with  disease, 
it  is  often  one  of  the  mildest,  most  beneficent,  and  least  hazard- 
ous of  remedies.  Dr.  J.  H.  Bennett  admitted  that  relief  of  pain, 
dyspnoea,  etc.,  sometimes  follows  bleeding;  and  this  concession 
carries  a  good  deal  with  it.  Dr.  Markham  and  others  have 
pointed  out  the  importance,  in  certain  cases,  of  relieving  an 
overloaded  heart  (right  auricle  and  ventricle)  by  venesection. 

How,  then,  it  is  proper  to  ask,  do  we  define  or  classify  the 
remedial  action  of  bloodletting  ? 

It  is  balancive.  What  do  we  mean  by  reducing  treatment? 
The  answer  to  this  question  is  important. 

J  do  not  know  of  a  single  case  of  any  hind  of  disease,  in  which  the 
indication  or  object  of  medical  treatraent  isTo  reduce  the  strength,  or 
lower  the  vital  power  of  the  patieyiVs  system. 

What  we  aim  to  reduce  is,  disproportionate  vascular  excite- 
ment, or  congestion ;  to  restore  the  balance  of  the  circulation. 
It  is  a  mere  imagination  that  abstraction  of  a  small  quantity  of 
blood  must  always  lower  the  patient's  strength.  Under  some 
circumstances,  it  actually  increases  it.  At  the  same  time,  there 
are  many  persons  wlio  will  never  hear  bleeding,  from  an  actual 
deficiency  or  defective  quality  of  blood. 

Taking  these  propositions  as  established,  we  may  draw  blood, 
locally  or  generally,  for 

1.  High,  sthenic  inflammation ; 

2.  Active  congestion,   tlireatening  inflammation  or  hem- 

orrhage ; 

3.  General  plethora,  ditto ; 

4.  Sthenic  spasm; 

5.  Sudden  passive  congestion  (not  toxsemic)  in  robust  persons. 

It  must  be  remembered  that,  at  the  present  time,  no  one  thinks 
of  bleeding /or /ever,  as  such. 

Repeated  venesections  are  seldom  now  resorted  to ;  the  time  for 
the  lancet,  if  at  all,  is  always  in  the  early  stage  of  a  phlegmasia. 

It  would  be  instructive,  if  compatible  with  our  plan,  to  allude 
further,  especially,  to  the  use  of  bloodletting  in  certain  cases  of 
pregnancy,^  and  of  convulsions ;  and  to  the  caution  necessary  in 
its  application  to  the  treatment  of  senile  apoplexy.  Old  persons 
rarely  bear  bleeding  Virell. 

We  might  also,  if  space  allowed,  illustrate  the  principles  above 
laid  down,  by  examples ;  as,  of  1,  erysipelas ;  2,  pneumonia ;  and 

1  See  a  valuable  paper  on  this  subject  by  Fordyce  Barker,  M.D.,  in  the  New  York 
Medical  Journal,  January,  1871. 


BLOODLETTING.  145 

3,  meningitis.  Why  is  bli^eding  seldom  called  for  in  the  first, 
more  frequently  in  Uie  second,  and  qait(!  often  in  the  last  ? 

Our  answer  is — that  it  depends  cliietiy  upon  the  anatomical 
relations  of  the  tissue  involved.  The  skin  is  unlimited  in  its 
opportunity  of  hypersemic  expansion,  and  escape  of  exudation. 
Tlie  lungs  are  partially  confined  and  limited,  by  the  pleura  and 
walls  of  the  chest.  The  brain  and  its  membranes  are  shut 
entirely  within  the  closed  skull.  Therefore  the  influence  of 
vascular  pressure  (which  is  most  alfected  by  bloodletting)  is 
most  marked  and  important  in  congestion  or  inflammation  of 
the  brain,  next  so  in  that  of  the  lungs,  and  least  of  all  in  that 
of  the  skin,  as  in  erysipelas. 

In  uraemia,  when  the  patient  will  bear  it,  moderate  venesec- 
tion may  do  good,  by  taking  out  excretory  material,  with  a  por- 
tion of  the  blood,  and  favoring  secretion  by  general  relaxation. 

Too  little  consideration  has  been  given  to  the  probable  effect 
of  venesection  in  removing  effete  corpuscles  and  altered  blood- 
2)l(isma,  so  as  to  promote  a  rcnewdl  of  'more  healthy  blood.  This 
may  explain,  in  part  at  least,  the  often  reported  improvement 
following  bleeding  (in  the  days  when  it  was  used)  in  cases  of 
zymotic  or  enthetic  diseases ;  as  scarlet  fever,  remittent  fever, 
yellow  fever,  etc. 

As  to  the  quantity  of  blood  taken  by  venesection,  twelve  fluid- 
ounces  may  be  stated  asafidl,  though  not  very  large,  bleeding 
for  an  adult  man ;  ten  fluidounces  for  a  woman.  For  infants 
and  children,  one  ounce  under  one  year,  two  ounces  under  three 
years,  three  ounces  under  live  years,  four  ounces  under  ten  years, 
would  be  a  full  average.  Bleeding  from  the  jugular  vein  has 
been  sometimes  preferred  in  young  children.  The  practitioner 
should  judge  for  himself  of  the  effect  upon  the  pulse,  etc.  It  is 
remarkable  how  small  an  amount  will  sometimes  do  a  great  deal 
of  good.^ 

Cut  cups  and  leeches  act  alike  as  to  the  abstraction  of  blood, 
but  the  former  have  a  more  revulsive  or  counter-irritant  eflect. 

Leeching,  being  somewhat  less  violent,  is  more  applicable  than 
cupping  to  parts  which  are  very  tender;  as,  the  side  in  acute 
pleurisy  ;  the  abdomen  in  peritonitis  ;  a  nmch  inflamed  joint,  etc. 

Leeches  are  usually,  for  the  same  reason,  applied  as  near 
as  possible  to  the  part  inflamed ;  cups,  sometimes,  at  a  short 
distance  from  it.  In  some  cases  the  tnechanical  leech  of  Dr. 
Andrew  H.  Smith,  of  New  York  (anticipated  by  Heurteloup), 
has  decided  convenience  and  advantage.'' 

In  bronchitis^  it  is  ordinarily  best  to  apply  leeches  or  cups  to 
the  upper  sternal  region. 

In  pneumonia,  they  may  be  preferably  applied  between  the  shoul- 


1  See  the  Chicago  Med.  Journal,  September,  1875,  for  an  instance  of  periodical  blood- 
lettinR,  to  the  auiount  of  eight  ounces  every  three  weeks,  kept  up  for  forty  years ;  the 
subject  beiug  cij,'hty  years  old  when  the  report  was  made.  I  was,  myself,  bled  thirteen 
times  from  the  arm  before  coming  of  age  ;  and  afterwards  was  bled  and  leeched  at  the 
beginning  of  an  attack  of  typhus  fever,  before  the  diagnosis  was  made  out ;  yet  I  con- 
tinue to  live,  and,  oa  the  basis  of  this  and  much  other  experience,  to  believe  in  the 
occasional  -use  of  the  lancet. 

2  See  N.  Y.  Medical  Kecord,  Nov.  1,  1869,  and  Feb.  1,  1873. 

13  K 


146  GENEKAL    THERAPEUTICS. 

ders,  as  a  general  rule,  thus  leaving  room  for  counter-irritation  in 
front. 

In  pleurisy,  it  is  desirable  to  use  leeches  immediately  over  the 
inflamed  part. 

Purgation,  especially  by  saline  cathartics,  is  a  frequently  use- 
ful part  of  antiphlogistic  treatment. 

Cathartics  are  to  be  avoided  in  enteritis  and  peritonitis ;  for 
obvious  reasons.  Yet  laxative  enemata  may  be  called  for  in  those 
affections,  to  prevent  the  evils  resulting  from  constipation. 

Diet,  in  cases  of  sthenic  inflammation,  should  be  non-stimulant; 
but  it  may  be  sufficiently  nourishing  (vegetable,  farinaceous)  at 
the  same  time.  Starving  patients  is  not  now  tliought  of,  unless 
they  are  fearfully  plethoric.  In  the  later  stages  of  inflammatory 
disorders — in  fact,  as  soon  as  the  exudation  has  all  heen  thrown  out, 
generous  diet  is  usually  required.  Some  patients  will  never  bear 
a  purely  vegetable  diet  under  any  circumstances ;  and  some  cases, 
even  of  inflammation,  require  stimulation  from  the  first. 

The  idea  of  the  association,  always,  of  low  diet  with  inflamma- 
tion, has  been  too  absolute  in  common  practice.  When,  in  acute 
disease,  the  stomach  refuses  to  digest  food,  it  is  vain  to  force  it 
upon  it.  But,  it  will  often  digest  liquid  food  when  it  cannot 
solids.  And,  as  some  degree  of  debility  is  constant  in  disease, 
alimentation  being  necessary,  concentrated  liquid  food,  e.  g.,  beef- 
tea,  will  frequently  be  appropriated,  when  no  solid  substance  at 
all  can  be  taken. 

I  believe  the  principal  requisites  of  diet  in  illness  to  be,  liquid- 
ity, and  facility  of  digestion  and  assimilation.  In  an  irritable, 
febrile  state  of  the  system,  the  presence  of  a  solid  body,  as  meat 
or  bread,  in  the  stomach,  when  no  digestive  fluid  is  secreted  to 
act  upon  it,  has  the  effect  of  a  foreign  substance — namely,  irrita- 
tion ;  sympathy  with  which  may  disturb  or  increase  existing  dis- 
turbance of  the  whole  economy. 

Practically,  I  have  seen,  in  a  person  not  robust,  suffering  from 
catarrhal  fever,  the  drinking  of  a  wineglassful  of  beef-tea  fol- 
lowed by  a  copious  perspiration  and  cooling  of  the  skin.  Still, 
a  young  and  previously  healthy  patient  will  often  do  best  in  the 
early  stage  of  inflammatory  disease  upon  small  or  moderate 
amounts  of  what  are  called  articles  of  sick  diet ;  as  oat-meal 
gruel,  toast-water,  panada,  arrowroot,  etc.  In  disorders  not 
aflecting  the  bowels,  fruits,  especially  white  grapes  and  oranges, 
need  seldom  be  withheld.  They  are  often  refrigerant  and  use- 
ful ;  and  such  is  very  frequently  the  effect  of  lemonade,  which 
acts  as  a  good  diuretic  and  diaphoretic. 

The  most  powerful  of  antiphlogistic  (arterial  sedative)  medi- 
cines is  tartar  emetic. 

The  "contro-stimulant"  plan,  of  giving  very  large  doses  of  this 
drug  in  pneumonia,  pleurisy,  etc.,  has  been  abandoned  as  exces- 
sive and  injurious.  We  need  never  give  more  than  I-  of  a  grain 
of  tartar  emetic  at  a  dose  to  an  adult— oftener  |,  j\,  etc.  Chil- 
dren require  especial  caution  in  its  use,  on  account  of  the  sensi- 
tiveness of  the  alimentary  canal  in  them.  I  have  known  severe 
vomiting  to  be  induced  iu  an  infant  by  -^^  of  a  grain.     No  other 


NITRATE    OF    POTASSIUM  —  ERGOT.  147 

medicine  as  yet  discovered,  liowover,  is  so  useful  in  the  most 
violent  intiammations  of  the  lungs,  bronchial  tubes,  etc. 

Tartar  emetic  (of  course)  must  never  be  given  in  gastritis  or 
6ii1;6rit/is 

Nitrate  of  potassium  is  a  valuable  adjunct  to,  or  in  some  cases 
substitute  for,  the  antimon'ial  tartrate."  It  is  often  given  m  too 
small  doses.  Ten  grains  may  be  a  minimum  for  an  adult,  if  the 
stomach  is  in  an  ordinary  state. 

Ipecacuanha  is  especially  valuable  in  bronchial.,  tracheal^  and 
lart/nyeal  intlainniation  and  in  (h/sentery. 

Veratrum  viride  (Osgood,  Norwood,  J.  Lewis  Smith)  has  as- 
sumed a  somewhat  in}portant  place  as  a  cardiac  and  arterial 
sedative,  and  promoter  of  the  secretions.  It  is  a  very  certain 
reducer  of  the  pulse,  but  requires  caution  in  its  use. 

Aconite  is,  likewise,  a  favorite  medicine  v/ith  some  practition- 
ers (A.  Fleming,  S.  Ringer,  C.  D.  Phillips,!  C.  West)  in  the  man- 
agement of  pleurisy,  pneumonia,  etc.  It  must  be  given  in  small 
doses  and  with  great  caution.  Ringer's  method  is  to  give  it  very 
early  in  acute  inllammatory  diseases ;  half  a  drop  or  a  drop  of 
the  tincture  of  aconite  in  a  teaspoonful  of  water  every  ten  or  fif- 
teen minutes  for  two  hours,  and  afterwards  every  hour ;  reducing 
the  dose,  however,  if  prostration  ensue. 

The  power  digitalis  has  to  reduce  the  rate  of  action  of  the 
heart,'*  has  induced  the  expectation  (Schunlein)  that  it  would 
prove  a  reliable  antiphlogistic  remedy  ;  but  this  expectation  has 
been  generally  disappointed.  It  is,  however,  occasionally  useful 
in  bronchitis,  etc. 

Ergot  has  been  employed  with  a  similar  view,  rather  as  directly 
acting  upon  the  smaller  arteries.  It  is  possible  that  its  powers 
have  not  as  yet  been  sufficiently  appreciated ;  although  it  has 
been  increasingly  used  of  late  years,  especially  in  subacute  and 
chronic  inflammatory  affections  of  the  nervous  centres. 

The  place  of  mercury  appeared  some  years  ago  to  be  settled. 
Early  in  this  century,  nothing  was  more  common  than  inten- 
tional mercurial  salivation  in  the  treatment  of  almost  all  serious 
acute  and  even  chronic  diseases.  In  the  management  of  inflam- 
mation, in  addition  to  its  powerful  alterative  influence,  tending  to 
displace,  by  its  own  impression,  morbid  actions  and  conditions, 
it  was  believed  to  exert  a  peculiar  control  over  the  blood,  lessening 
the  tendency  to  the  effusion  of  coagulable  lymph. 
•  In  recent  times,  the  "•salivating"  practice  has  been  entirely 
abandoned,  as  disproportionately  violent,  as  well  as  uncertain. 
A  reaction,  somewhat  similar  to  that  occurring  in  the  case  of 
bloodletting,  has  shaken  the  confidence  of  many  practitioners  in 
the  value  of  mercury  as  an  antiphlogistic. 

My  own  opinion  is  this.  Experience  fully  warrants  the  infer- 
ence that  mercury  is  a  general  stimulant  to  all  those  functions  of 
organic  life  which  are  performed  under  innervation  from  the  ganglia 
of  the  (so-called)  sympathetic  system.  It  is  probable  that  its  action 
is  directly  upon  these  ganglia.    Thus,  mercury  tends  to  diffuse  and 

»  The  Practitioner,  April,  1871. 

2  Facts  have  been  accumulated  which  lend  force  to  the  opinion  that  digitalis  is  pri- 
marily, rather  a  tonic  than  a  sedative  to  the  heart. 


148  GENERAL    THERAPEUTICS. 

equalize  secretion,^  and  the  circulation  of  the  blood,  aiding,  in  this 
way,  to  break  up  local  congestions  and  inflammations.  More- 
over, it  promotes  the  disintegration  of  albuminoid  material,  such 
as  that  exuded  under  the  inflammatory  process.  Its  anti-syplii- 
litic  power  makes  it  important  in  specific  inflammations  ;  as  of 
the  iris,  etc. 

I  believe  that  calomel  and  blue  mass,  etc.,  have  been  shown  to  be 
useful  in  the  treatment  of  several  acute  disorders.  I  do  not 
think  that  a  due  regard  for  the  principles  of  evidence  in  thera- 
peutical science  can  allow  us  to  put  aside  the  proof  of  this,  deduced 
from  actual  experience.  Dr.  O.  H.  Smith,  of  Brooklyn,^  reports 
three  cases  of  urcemic  poisoning,  in  which  large  doses  of  calomel 
did  great  good  ;  two  in  pregnancy  with  convulsions,  and  one  in 
dropsy  after  scarlet  fever.  This  suggests  the  probable  action  of 
mercury  on  the  kidneys.  Dr.  Cyon,  of  St.  Petersburg,  performed 
experiments  seeming  to  render  it  probable  that  urea  is  formed  in 
the  liver;  as  blood  passed  through  the  liver  was  found  to  contain 
much  more  urea  than  ordinary  arterial  blood.  Grehaut's  experi- 
ments also  appear  to  show  that  the  kidneys  are  not  secretory,  but 
only  excretory  of  urea.^ 

Moderate  doses,  at  the  same  time,  are  capable  of  doing  all  that 
we  can  safely  aim  to  efiect  with  the  use  of  mercurials.  I  do  not 
know  of  any  variety  or  form  of  disease  in  which  I  should,  at  the 
present  moment,  feel  justified  in  intentionally  causing  full  saliva- 
tion as  a  means  of  medical  treatment. 

Mercury  is  especially  contraindicated  in  the  presence  of  the  tuber- 
cular diathesis. 

Opium,  always  the  most  reliable  and  potent  of  anodyne  medi- 
cines, has,  in  latter  times,  assumed  a  more  important  position  as 
a  remedy  in  the  treatment  of  inflammatory  diseases. 

Experience  has  warranted  this,  while  certain  theoretical  con- 
siderations also  have  been  urged  in  regard  to  it. 

1.  The  influence  of  the  nervous  centres  upon  inflammation  (as 
upon  normal  nutrition,  circulation,  etc.),  and  the  intimate  inter- 
connection of  the  two  portions,  organic  and  sensori-motor,  of  the 
nervous  apparatus,  are  now  more  fully  recognized  than  formerly. 

2.  Opium  is  believed  by  some  to  act  directly,  not  only  upon  the 
cerebro-spinal,  but  also  upon  the  ganglionic  nerwe-cells  as  a  pecu- 
liar stimulant,  thus  afiecting  the  circulation,  nutrition,  etc., 
otherwise  than  by  mere  sj^mpathy. 

Yet,  in  estimating  the  adaptation  of  preparations  of  opium  or 
morphia  to  the  treatment  of  inflammations  of  important  organs, 
in  different  stages,  we  must  remember  that — 

1  Very  few  points  in  practice  are,  for  instance,  so  well  sustained  by  experience,  as 
the  familiar  use  (after  Abernethy)  of  small  doses  of  blue  pill,  in  the  treatment  of  indi- 
gestion with  torpidity  of  the  liver,  and  bowels,  etc.  Supposing  that  the  conclusion 
based  (by  Bennett  and  others)  upon  experiments  on  animals  be  sustained,  that  mer- 
cury does  not  increase  the  flow  of  bile  from  the  liver ;  this  would  merely  involve  a 
change  in  the  explanation  of  its  therapeutic  action,  not  in  the  admission  of  the  often- 
observed  fact.  Dr.  Douglass,  of  Boston  (New  England),  first  introduced  the  use  of  mer- 
cury as  an  antiphlogistic.  Dr.  R.  Hamilton,  of  England,  generally  has  the  credit  of  it. 
Falconer,  Jas.  Hamilton,  Habershon,  and  Williams  of  Boston,  especially,  have  of  late 
years  written  against  it.  See,  in  support  of  its  cholagogue  action,  T.  R.  Eraser,  Edin. 
Med.  Journal,  April,  1871 ;  also,  Christison,  Murchison,  and  others. 

2  New  York  Medical  Record,  Nov.  15,  1870.  "  Ibid.,  Dec.  1, 1870. 


COUNTER -IRRITATION.  149 

Opium  is  an  arterial  stimulant,  and  is,  therefore  (as  a  general 
rule),  inappropriate  in  the  early  stage  of  an  active  sthenic  phleg- 
masia. 

Opium  first  excites,  and  then  ojjpresses  tlie  brain;  in  a  word,  it 
promotes  determination  of  blood  to  the  head  ;  and  is,  therefore, 
contraindioated  by  an  already  existing  tendency  to  cerebral  con- 
gestion. 

Opium  also  constipates  the  bowels — a  fact  of  less  importance  than 
either  of  the  two  preceding,  as  the  constipating  tendency  can  be 
counteracted,  if  desirable,  by  other  medicines  ;  while,  in  certain 
cases,  it  aids  in  the  treatment  (as  in  dysentery). 

In  jjmtoirt'tjs,  where  the  extent  and  visceral  connections  of  the 
tissue  affected  induce  more  rapid  prostration  and  more  serious  ner- 
vous irritation  than  in  any  other  phlegmasia,  opium  has  become  the 
main  dependence  with  very  many  practitioners,  even  from  the 
beginning  of  the  attack.  The  same  reasoning  will  apply,  to  a  some- 
what less  extent,  to  its  use  in  severe  cases  oi pleurisy  and  pericar- 
ditis. 

Counter-irritation  is  a  measure  of  treatment  often  of  great  ser- 
vice, especially  in  the  later  stages  of  inflammation  (after  local  or 
general  depletion,  etc. ),  or  in  cases  unattended  with  much  vascular 
excitement.  In  the  very  incipiency,  or  rather  incubation,  of  an 
inflammatory  attack,  i.  e.,  in  the  stage  of  mere  irritation  or  conges- 
tion, counter-irritation  (e.  g.,  by  a  sinapism)  m?ij prevent  the  further 
progress  of  the  inflammatory  process.  But,  if  the  stasis  and  con- 
centric hypersemia  be  already  developed,  all  potcerful  counter-irri- 
tants should  be  avoided  (lest  they  prove  co-irritants)  until  the 
vascular  disturbance  has  subsided.  Schiiller^  ascertained  by 
experiments  upon  animals  that,  by  sinapisms,  blistei-s,  etc.,  it 
is  possible  to  diminish  the  blood-contents  of  the  cerebrum.  A 
measure  whose  usefulness  I  have  seen  amply  demonstrated,  is 
the  application  of  a  blister  to  the  whole  shaven  scalp  in  severe 
cases  of  inflammation  of  the  brain.  Early  use  of  large  warm  mush 
and  mustard  poultices  (one  part  mustard  mixed  with  four  parts 
mush)  is  a  xery  useful  measure  in  pineumonia  and  pleurisy. 

In  subacute  cases,  or  those  of  moderate  irritation  or  inflamma- 
tion, as  in  chronic  broyichitis,  etc.,  a  good  means  of  counter-irri- 
tation is,  painting  the  skin  thickly  with  tincture  of  iodine.  More 
powerful  derivative  eftect  is  obtained  by  the  application  of  a  few 
drops  of  croton  oil  (diluted  with  three  or  four  times  as  much  olive 
or  lard  oil)  over  the  part ;  producing  a  sore  papular  eruption. 
With  children,  or  women  having  a  very  delicate  skin,  friction 
with  oil  of  turpentine  will  cause  considerable  derivation  to  the 
skin,  over  or  near  an  inflamed  part. 

Counter-irritation  is,  usually,  the  most  imjjortant  part  of  the 
treatment  of  hypersemsetliesia,  or  "  chronic  inflammation," 

Under  the  head  of  counter-irritation  we  may  place  the  power- 
ful impression  made  by  the  actual  cautery.  Brown-S^quard  has 
made  much  use  of  this,  especially  for  chronic  affections  of  the 
nervous  system.  It  is  reported  to  relieve  or  greatly  mitigate  the 
sufiering  produced  by  neuralgia,  as  well  as  the  lancinating  pains 

1  CerliLer  Kliuische  Wocheuschrift,  Nov.  25,  1874. 
13* 


150  GENERAL    THERAPEUTICS. 

of  locomotor  ataxy ;  and  to  assist  much  in  the  treatment  of  obsti- 
nate cases  of  chorea,  hysteria,  epilepsy,  catalepsy,  and  general 
paralysis.  No  special  instrument  is  needed  ;  a  small  poker  will 
do.  Best,  is  a  steel  or  platinum  bulb,  shaped  like  an  olive  but 
smaller.  White  heat  gives  less  pain  than  a  lower  temperature. 
Quick,  light  touches  sliould  be  made,  burning  the  skin  only  in 
points  and  lines.  The  seat  of  application  should  be,  generally, 
not  far  from  the  location  of  the  disease  for  which  it  is  used. 
Most  patients  will  require  to  be  placed  under  the  influence  of  an 
anaesthetic  for  this  operation.  The  cauterized  spots  may  be,  with 
advantage,  touched  withpz«re  carbolic  acid  (to  reduce  sensibility). 
and  then  dressed  with  simple  cerate,  or  wet  lint  (water  dressing) 
until  healed. 

To  recapitulate  the  order  of  time,  in  which  long-recognized 
experience  has  prescribed  the  use  of  the  different  means  now 
included  under  the  term  "antiphlogistic"  treatment : — 

Supposing  all^  of  the  main  remedies  of  this  class  to  be  called  for 
in  a  given  case,  we  would  resort  first  to  venesection;  or,  if  this  be 
undesirable,  to  cupping  ot  leeching ;  next,  to  saline  purgation  ;  then 
to  tartar  emetic,  nitrate  of  potassium,  ipecacuanha,  veratrum 
viride  or  aconite  ;  mercury,  if  given,  at  the  same  time,  or  imme- 
diately following  these  sedatives ;  opium,  sometimes  with  it  or 
them — oftener,  a  little  later  ;  counter-irritation  by  blisters,^  etc., 
last.  The  subsequent  debility,  especially  in  cases  of  suppurative 
inflammation,  may  call  for  tonics  or  even  stimulants,  with  gener- 
ous diet,  etc. ;  while  certain  asthenic  cases  will  even  require  such 
treatment  from  the  first. 

The  treatment  of  subacute  or  chronic  inflammation,  in  external 
or  accessible  parts,  by  astringents  or  stimulants  (e.  g.,  nitrate  of 
silver),  does  not  require,  in  this  place,  extended  discussion;  as  it 
usually  comes  under  the  domain  of  Surgery.  One  example,  how- 
ever, of  its  medical  utility  may  be  named — viz. ,  the  administra- 
tion of  nitrate  of  silver  (gr.  J-|  ter  die)  in  chronic  gastritis.  The 
chemical  change  which  it  undergoes  in  the  intestines,  when  given 
by  the  mouth,  explains  the  fact  that  the  same  medicine  fails  to 
exhibit  a  similar  beneficial  influence  in  chronic  enteritis.  In  pro- 
longed dysentery,  however,  enemata  containing  this  or  some  anal- 
ogous mineral  salt,  as  sulphate  of  zinc,  sulphate  of  copper,  or 
acetate  of  lead,  are  often  very  valuable  remedies. 

We  cannot  leave  the  subject  of  the  management  of  inflamma- 
tory disease  without  reminding  the  student  of  the  important  prac- 
tical diflerence  between  sthenic  and  asthenic  inflammations.^ 

The  diff"erence  is  constituted — 

1.  By  the  state  of  system  of  the  patient  afiected ; 

2.  By  the  nature  of  the  producing  cause. 

1  Of  course,  this  supposition,  of  the  successive  use  of  all  of  the  remedies  named  in  this 
paragraph,  does  not,  in  very  many  cases,  need  to  be  realized. 

-TJv.  Inman,  of  Liverpool,  suggests  that  the  so-called  counter-irritants  really  act,  by 
absorption,  as  direct  stimulants,  to  parts  enfeebled  by  disease.  It  is  quite  probable  that, 
in  some  cases,  this  may  be  true.  Sinapisms,  friction  with  liniments,  etc.,  for  superficial 
stimulation  and  counter-irritation,  may  be  used  in  the  earliest  stages  of  an  internal 
iniiammation. 

3  Granting  that  all  disease  is  deMKtaling  (Inman),  the  distinction  is  still  valid  and 
important,  as  to  the  ditferent  kinds  and  degrees  of  depression  produced  by  its  ditfereut 
forms  or  types. 


FEBRIFUGE    TREATMENT.  151 

One  whose  constitution  has  been  prosliated  l)y  previous  disease 
or  recent  excess,  will  have;,  when  exposed  to  the  ordinary  causes 
oi"  in^anmiation,  an  (isthenic  attack;  t.  ('.,onc  in  whicii,  witli  all 
the  local  symptoms  of  phloi^osis,  the  (jeneraL  onjanic  functions  (ire 
sympathelkally  ajD'ccted  rulker  wUk  depression  than  with  excitement. 

Again,  certain  morbid  poisons  induce,  with  toxaemia,  local 
inflammation;  and  blood-disease  (dyscrasia),  arising  from  various 
causes,  may  have  local  intlannnation  as  a  secondary  effect.  In  tluvse 
cases,  the  type  of  the  intlannnation  is  generally  asthenic,  and  the 
treatinent  must  be  modified  accordingly — depletion  being  avoided, 
or  used  with  the  greatest  caution,  and  strong  diet  and  even  stim- 
ulation being  not  unfrequently  called  for. 

As  examples  of  intlammations  which  may  be  either  sthenic  or 
asthenic,  we  may  mention  erysipelas,  dysoUery,  peritonitis,  pneu- 
monia, gout. 

The  tirst  three ^  of  these  are  at  times  epidemic;  and  then  it  is 
that  the  greatest  number  of  asthenic  cases  is  observed.  The  fol- 
lowing maxim  may  be  considered  as  fully  established :  — 

Whenever  any  local  affection,  as  dysentery,  peritonitis,  catarrh,  or 
'pneumonia  occurs  sometimes  sporadically  (i.  e.,  in  altogether  sepa- 
rate or  independent  cases)  and  sometimes  endetnically  or  epidemi- 
cally («".  e.,  a  number  of  cases  at  the  same  place  and  time,  under 
a  common,  local,  or  temporary  cause),  the  latter  cases  exhibit,  as  a 
rule,  the  (jreatest  tendency  to  depression  in  their  symptoms,the  largest 
mortality,  the  least  tolerance  oj  depletory  treatment,  and  the  m,ost  fre- 
quent need  of  stimulation  or  support. 

By  febrifag'e  treatment  I  mean,  that  which  is  proper  during 
the  existence  of  the  febrile  state.  It  comprises  no  violent  meas- 
ures of  any  kind. 

Remembering  that  the  essential  phenomena  of  fever  are, 
increased  heat,  especially  of  the  exterior  of  the  body,  dryness  of 
its  surfaces,  scantiness  ot'  fluid  in  all  the  discharges,  with  actual 
increase  in  their  solids,  from  accelerated  tissue-metamorphosis — our 
therapeutics  must  be  adapted  to  these  conditions.  Apart  from 
the  necessity  of  removing  or  antagonizing,  if  possible,  the  cause 
of  the  febrile  disturbance,  the  indications  are  to  allay  the  heat 
and  dryness  of  the  surfaces  of  the  body,  tegumentary  and  mucous, 
and  to  favor  the  removal  of  excreta,  accumulated  in  unusual 
amount  in  the  blood  and  organs. 

For  these  purposes,  we  may  use 

Moderate  laxatives;  Cold  drinks; 

Saline  diaphoretics;  Cool  ablutions. 

Of  these  measures,  I  have  no  doubt  of  the  propriety  of  the  desig- 
nation of  water  as  the  heroic  remedy,  to  which  the  others  are 
merely  adjuvants.  Diaphoretics  will  scarcely  act  at  all  without 
free  imbibition  of  water,  and  the  operation  of  laxatives  is  much 
promoted  by  it.  Water  alone  is  diaphoretic,  diuretic,  and  laxa- 
tive ;  but  it  may  be  aided,  to  an  important  degree,  in  alleviating 
the  symptoms  of  fever,  by  the  addition  to  it  of  aitrate  of  potas- 

1  I'uyumouia  also  is  sometimes  endemic  or  epidemic,  ia  the  form  of  typhoid  pueu- 
mouia. 


152  GENERAI,    THERAPEUTICS. 

Slum,  acetate  of  ammonium,  etc.  Dr.  J.  F.  Meigs  found,  by  meas- 
urement, that  tlie  daily  amount  of  water  taken  voluntarily  by 
each  of  three  patients  with  continued  fever,  having  a  tempera- 
ture of  103°  or  104°  Fahr. ,  was  from  110  to  120  ounces.  Thirst 
is  the  natural  and  proper  criterion  for  its  use.  Yet  the  tempera- 
ture of  ice-water  is  too  low  for  such  copious  imbibition.  Ordinary 
spring  or  well  water  (50°  to  60°  Fahr.)  is  quite  cold  enough. 
Manassein,  of  St.  Petersburg,  asserts  good  effects  fi'om  the  use  in 
hot  fever  of  cool  or  cold  enemata  for  refrigeration.^ 

"Within  a  few  years  the  revival  has  occurred  of  a  practice  sim- 
ilar to  that  of  Dr.  Currie,^  of  Liverpool,  using  the  cold  bath  as  a 
remedy  for  hyperpyrexia  in  typhoid  and  other  fevers.  This  revival 
appears  to  have  been  chiefly  due  to  Ernst  Brand,  1861.  Besides, 
Niemeyer,  Ziemssen,  Liebermeister,  and  Traube  have  especially 
employed  the  method  referred  to,  in  G-ermany;  as  have  also 
Behier  in  France,  and  Wilson  Fox  in  England.  Brand  applied 
cold  douches  to  the  upper  part  of  the  body  of  the  fever  patient, 
the  lower  portion  being  placed  in  a  cold  bath.  Liebermeister,  at 
Basle,  immersed  the  patient  in  water  at  68°  Fahr.  for  ten  min- 
utes at  a  time ;  sometimes  repeatedly  during  the  same  day.  These 
measures  appear  violent ;  and  they  are  certainly  not  always  suc- 
cessful, or  even  safe. 

Ziemssen's  method  is  manifestly  the  best.  He  introduced  (at 
Erlangen)  the  graduated  full  bath  for  fever.  The  patient  is  placed 
in  water  at  95°  Fahr.,  and  its  temperature  is  then  gradually  low- 
ered, while  he  is  in  it,  down  to  86°,  80°,  or,  when  the  effects  have 
been  shown  to  be  good,  on  repetition,  to  70°  or  68°.  In  this  way 
all  the  danger  (which  has  been  shown  to  be  real)  as  well  as  the 
discomfort  of  the  sudden  shock  of  a  low  temperature,  is  avoided  ; 
while  the  full  benefit  of  the  abstraction  of  heat  is  obtained.  Wiin- 
derlich  has  expressed  preference  for  this  method.  Extensive 
trial  of  this  cold-immersion  treatment  of  typhoid  fever,  in  this 
country  as  well  as  in  Europe,  has  led  to  the  conclusion  (Flamma- 
rion,  Grimshaw,  Peters,  Pepper,  Flint)  that  it  does  not,  on  the 
whole,  diminish  the  mortality  of  typhoid  fever ;  and  that,  in  a 
certain  number  of  cases,  it  may  even  do  serious  harm.  Cold 
sponging,  and  inunction,  with  lard  or  olive  oil,  are  much  safer,  and 
often  very  beneficial  measures  for  reduction  of  excessive  tempera- 
ture. 

1  have  already  laid  emphasis  upon  the  statement,  that  no  one 
now  thinks  of  bleeding  for  fever,  as  such.  In  a  much  more  strict 
sense,  pathologically  speaking,  than  inflammation,  the  febrile  nisiis 
is  self-limited,  although  variable  in  its  duration  according  to  the 
cause  inducing  it.  The  object  of  the  physician  is  not  to  cut  it  short 
(jugulare),  but  to  conduct  it  safely  to  a  critical  termination.  In 
an  equally  important  practical  manner,  this  principle  applies,  not 
only  to  the  management  of  a  brief  or  ephemeral  exacerbation  or 

1  Med.  Times  and  Gazette,  July  19, 1879.  Several  other  Russian  physicians  have  made 
large  use  of  cold  enema:  a  iu  levers.     See  Practitioner,  January,  188U. 

'■i  Currie  wrote  in  1797 ;  his  first  experiments  with  eold  affusion  were  made  in  1787. 
Hancock,  Wright,  Brandreth,  Lind,  Willis,  and  E,at>ert  Jackson  preceded  him  ;  and  so 
had  Cirillo  of  Naples,  De  Hahn  (Breslau,  1737),  Samoilowitz  (Moscow,  1771),  and  others. 
Indeed,  in  tetanus,  and  sometimes  in  fevers,  even  Hippocrates,  Galen,  and  Avicenna 
used  cold  affusion  or  the  cold  bath.    What  is  there  new  under  the  sun? 


FE15RIPUGE    TREATMENT.  153 

parox3sm  of  irritative  or  roactivc  fever,  but  also  to  those  of 
longer  duration,  under  toxaeniic  (zymotic)  causation;  as  exan- 
ihemalous  (rubeolar,  scarlatinal,  variolous)  or  continued  (typhus, 
typhoid)  fevers.  An  exception  is  believed  by  many  to  exist,  in 
the  case  of  autumnal,  malarial,  periodical  fevers,  i.  e.,  interndttent, 
remittent^  and  pernicious  (co'ngestivej ;  in  which,  interference  by 
the  antidntal  remedy,  cinchona  or  its  alkaloids,  is  considered  safe 
at  all  times,  and  sometimes  necessary  before  the  sul)sidence  of 
fever.  But  I  believe  this  exception  to  be  only  partial,  since  care- 
ful recorded  experience  has  given  rise  to  the  conclusion'  that 
quinine  is  S(!ldom  necessary  during  the  heir/lit  of  the  exacerbation 
of  either  type  of  malarial  fever,  and  that  in  large  doses  at  that 
period  it  may  do  harm.  It  is,  I  consider,  the  best  practice  gen- 
erally, in  the  treatment  of  autumnal  remittent  fever,  to  wait  iiiitil 
the  febrile  stage  has  passed  its  climax,  and  its  symptoms  have  beytm 
to  decline — the  urgency  of  the  case,  and  all  its  circumstances, 
then,  guiding  the  practitioner  as  to  how  soon,  as  well  as  how 
largely,  the  special  remedy  must  be  introduced. 

It  is  needful,  however,  in  this  connection,  to  refer  to  the  appro- 
val by  Sir  Thomas  Watson  of  the  use  of  opium  in  the  hot  stage 
of  intermittent  fever;  as  well  as  the  employment,  with  reported 
success  (Squire),  of  quinine  in  the  pyrexia  of  scarlet  fever,  and  of 
the  same  remedy  in  full  doses  in  pyoemia,  by  Dr.  Fordyce  Barker 
and  others.  In  Germany,  quinine  is  often  much  given  during 
fever,  to  reduce  the  tenqjeratnre. 

Antipyretic  treatment,  of  a  very  positive  and  active  kind,  is  much 
in  vogue  at  the  present  day.  Its  chief  weapon,  besides  immersion 
in  cold  baths,  consists  in  the  administration  of  fifteen  or  twenty- 
grain  doses  of  quinine;  or,  of  corresponding  amounts  of  salicylic 
acid  or  resorcin.  Without  recent  personal  observation  of  this 
last  practice,  I  am  convinced,  by  the  results  of  a  careful  trial  of 
quinine  in  typhoid  fever  in  the  Pennsylvania  Hospital  (Dundas's 
treatment)  many  years  ap;o,  and  by  the  reports  of  the  compara- 
tive mortality  where  antipyretic  measures  have  been  vigorously 
pushed,  that  it  is  an  uncertain,  if  not  a  hazardous  method  of 
medication.  Such  an  impression  of  quinine  upon  the  nervous 
centres  as  is  necessary  to  abate  the  high  temperature  of  (non- 
malarial)  fevers,  is  too  powerful  to  be  likely,  on  the  whole,  to 
benefit  the  progress  of  those  maladies.  Exception  does  not  seem 
yet  to  be  proved  to  the  rule,  that  typhoid  and  typhus  fevers  can- 
not he  '•'■  jugidated,''''  being  typically  self-limited  diseases',  but  must 
be  carefully  conducted,  with  very  little  interference,  to  th^ir  close. 
Sir  William  Jenner,'^  in  an  admirable  summary  of  the  results  of 
experience  in  the  treatment  of  typhoid  fever,  has  given  the  weight 
of  his  authority  to  the  non-acceptance  of  this  heroic  and  abortive 
"  antipyretic  "  practice. 

Moreover,  it  is  extremely  important  that  the  indication  for 
elimination  of  excreta  in  all  acute  febrile  maladies  (e.  g.,  scarlet 

1  See  Medical  Statistics  of  United  States  Army,  1839-54. 

*  Address  before  Birmingham  Medical  Institute ;  Lancet,  November,  1879,  p.  715.  See, 
for  testimony  against  the  cold-bath  treatment  fBiermer,  Lindworm.  Lichtenstein,  Wiin- 
derlich,  Griinshaw,  Pepper,  Peters)  a  paper  by  F.  Allport.  M.  I).,  N.  Y.  Med.  Record,  No- 
vember, 1879,  p.  414.    Bristowe,  also,  has  proiiounced  against  it. 


154  GENERAL.    THERAPEUTICS. 

fever,  measles,  small-pox,  etc. )  should  not  be  neglected.  Early 
opening  of  the  bowels,  and  free  action  of  the  skin  and  kidneys  are 
of  the  greatest  consequence  in  such  affections.  "When  diarrhoea 
is  present,  it  should  be  merely  held  in  check  (not,  usually,  sup- 
pressed) with  much  caution.  I  have  more  than  once  known  death 
to  result  from  premature  locking  up  of  the  secretions,  by  opium,  etc., 
in  acute  febrile  disorders,  which,  probably,  otherwise  might  have 
done  well. 

Of  medicines  which,  without  undue  depression,  tend  to  refriger- 
ate the  system  in  fever,  acids,  vegetable  and  mineral,  as  well  as 
their  salts,  have  long  been  commended  by  experience.  Citric  and 
acetic  acids,  even  when  combined  (as  in  solutions  of  citrate  of 
potassium  or  acetate  of  anamonium)  are  the  general  favorites  for 
this  purpose.  In  continued  fevers  (typhus  and  typhoid)  hydro- 
chloric, nitric,  and  nitro-muriatic  acids  are  often  of  great  service. 
In  connection  with  this  clinical  experience  may  be  mentioned 
the  suggestive  fact,  that  physiological  experimentation  (Gaskell, 
Lancet,  Sept.  18,  1880)  has  shown  the  direct  influence  of  acids 
to  be  depressive  of  the  action  of  both  the  heart  and  the  arteries, 
while  alkalies  have  the  reverse,  or  a  tonic  eftect. 

It  is  a  matter  of  general  remark,  that  patients  scarcely  ever 
die  during  the  hot  stage  of  any  kind  of  fever.  In  the  most  intense 
form  of  malarial  poisoning,  called  pernicious  fever,  the  danger 
exists  in  the  extreme  depression  of  the  cold  stage;  if  fever  comes 
on,  the  patient  is  comparatively  safe  for  the  time. 

The  supporting  treatment  is  that  adapted  to  states  of  prostra- 
tion or  deoility. 

General  weakness  of  the  body  (when  not  a  congenital  defect) 
occurs  under  three  forms — 

Exhaustion ; 
Depression ; 
Oppression. 

We  are  familiar  with  the  first,  exhaustion,  as  the  effect  of  over- 
exertion, loss  of  sleep,  deficiency  of  food,  excessive  discharges,  etc., 
and  as  following  acute,  or  constituting  a  pa7't  of  chronic  disease. 

The  second,  depression,  is  to  be  discriminated  from  exhaustion, 
as  resulting,  not  from  expenditure  or  waste  of  the  material  or 
forces  of  the  body,  but  from  interference  with  their  normal  activity 
by  some  disturbing  cause.  To  use  a  mechanical  illustration, 
exhaustion' is  the  running  down  of  the  clock;  depression  the  arrest 
of  the  iziipelling  movement  of  the  weights  or  spring,  by  which  its 
wheels  are  kept  in  motion. 

Oppression,  then,  may  be  compared  to  the  obstruction  of  the 
machinery  by  some  foreign  body,  or  by  some  mechanical  disar- 
rangement among  the  wheels,  which  clogs  their  action  until  it  is 
removed  or  corrected. 

Exhaustion  and  depression  have  their  chief  seat  in  the  nerve- 
central  sources  of  dynamic  force ;  oppression,  in  the  circulation 
of  the  blood,  or  in  some  subordinate  organs  or  functions. 

This  distinction,  however  recondite  in  theory  it  may  seem  to  be,  is 
of  high  practical  importance.  This  will  be  seen  on  consideration 
of  the  remedies  used  and  required  in  the  different  forms  of  debility. 


SUPPORTING    TREATMENT.  155 

Supporting  measures  may  be  classified  as — 

1.  Stimulant; 

2.  Analeptic  (recuperative,  restorative). 

Under  the  first  head  we  rank  the  preparations  o[  ammonia  and 
alcohol,  etc.,  as  usually  employed. 

Under  the  second  are  included  generous  diet,  tonics,  clialybeates, 
cod-liver  oil,  chanije  of  air,  etc. 

Now  the  first  of  these  (stimulants)  are  adapted  especially  to 
acute  prostration  or  depressio^i;  the  second  class  (analeptics),  to 
c/iroJiic  prnstrrdion  or  exhaustion.  Oppression  or  cowderfeit  debility 
generally  requires  neither,  being  benefited  by  very  different  treat- 
ment. A  minyling  or  blending  of  these  states  is  of  course  possible ; 
and  then  a  union  of  measures  is  right,  to  meet  the  conjoined  indi- 
cations. 

Oppression  (simulating  depression)  is  every  day  illustrated  by 
the  condition  of  a  patient  in  the  early  stage  of  any  of  even  the 
mildest  acute  disorders ;  as  catarrh  or  bronchitis,  indigestion, 
tonsillitis,  measles,  etc.  In  all  of  these  cases,  especially  where 
fever  is  developing,  the  patient  is  very  iveak ;  not  only  as  to  his 
muscular  apparatus,  but  in  the  performance  of  all  the  animal  and 
organic  functions.  But  stimulation,  for  such  a  condition,  in  per- 
sons of  ordinary  constitutional  vigor  and  soundness,  would  be 
generally  inapjpropriate,  often  injurious,  sometimes  dangerous. 

A  more  serious  degree  of  oppression  occurs  in  some  cases  of 
visceral  congestion,  particularly  of  the  lungs  or  brain ;  and  in 
violent  spasmodic  affections  of  the  alimentary  canal,  with  consti- 
pation of  the  bowels.  Urcemia,  from  inaction  of  the  kidneys, 
presents  another  case  of  oppression,  in  which  even  a  fatal  result 
may  occur. 

Counterfeit  debility  or  oppression,  then,  to  recapitulate,  may 
occur  in — 

The  first  stage  of  all  acute  diseases; 
The  febrile  state; 
Indigestion  or  dyspepsia; 
Congestion  of  the  brain,  lungs,  etc.  ; 
Obstruction  of  the  bowels; 
Urcemia. 

The  first  of  these  instances  is  to  be  treated  usually  by  measures 
which  promote  reaction  in  the  mildest  manner.  More  doubt 
exists,  however,  if  the  cold  stage  itself  be  intense  or  profound — 
as  in  pernicious  intermittent — constituting  a  depression  under 
toxeemic  influeiice.     Of  this,  a  word  or  two  presently. 

The  febrile  oppression  is  to  be  managed  simply  ]jy  those  pallia- 
tive measures  mentioned  already  under  the  head  of  febrifuge 
treatment. 

That  of  indigestion  is  usually  temporary  or  occasional  only  ;  and 
gives  way  under  the  use  of  antacids,  carminatives,  blue  pill,  etc. 

Violent  congestion  of  the  brain  or  lungs  occurring  in  a  person  of 
previously  good  constitutional  strengtli  (although  it  may  produce 
the  most  absolute  debility,  which,  especially  in  the  case  of  pid- 
monarg  congestion,  masks  tlie  cause  of  the  disorder  i,  calls,  if  the 
diagnosis  be  clear,  for  counter-irritation  and  the  local  or  general 


156  GENERAL    THERAPEUTICS. 

abstraction  of  blood.  In  doubtful  cases  a  tentative  plan  may  be 
pursued  ;  abstracting  but  a  minimum  quantity  at  first,  being  en- 
couraged to  repeat  and  enlarge  the  depletion  only  if  the  result  be 
favorable. 

Constipation,  producing  oppressive  debility,  is  of  course  to  be 
met  by  agents  calculated  to  unload  the  bowels  ;  antispasmodics, 
anodynes,  etc.,  being  also  indicated  if  colic  exist,  and  be  not 
relieved  by  laxatives  alone.  In  absolute  (mechanical)  obstruction 
of  the  bowels,  as  intussusception  or  internal  strangulation,  the 
treatment  now  generally  adopted  is,  to  depend  ^  upon  opium  and 
rest,  avoiding  purgatives. 

Urcemia  demands  all  the  means  within  our  power  to  restore  the 
action  of  the  kidneys  ;  and  to  aid  them  in  their  eliminating  duty 
by  favoring  the  cutaneous  transpiration  and  secretion. 

I  have  already  said  that  mixed  cases  of  oppression  and  depres- 
sion occur,  in  which  the  indications  of  treatment  are,  to  a  certain 
extent,  obscure  and  doubtful.  Such  are,  the  cold  stage  of  perni- 
cious (congestive)  intermittent,  the  incipiency  of  the  algid  or 
collapsed  state  of  epidemic  cholera,  etc. 

It  is  clear  that  reaction  is  here  to  be  brought  about,  if  possible  ; 
and  that  external  stimulation,  by  powerful  rubefacients,  frictions, 
etc.,  is  altogether  appropriate  ;  but,  however  authoritatively 
rules  may  have  been  laid  doAvn,  it  is  not  so  certain,  in  every  case, 
whether  alcoholic  stimulation  or  venesection  would  afford  the  better 
result,  or  whether  some  cases  might  not  be  benefited  by  both  com- 
bined. The  incompatibility  supposed  to  exist  between  bloodletting 
and  stimulation  is  in  fact  nut  intrinsic  but  circumstantial.  Hold- 
ing distinctly  in  our  minds  the  principle  that  the  object  of  blood- 
letting is  to  balance  the  quantity,  consistency,  and  distribution 
of  the  blood,  and  7iot  to  reduce  the  strength  of  the  patient,  it  is 
far  from  impossible  that  the  balancive  action,  especially  of  local 
bloodletting,  may  be  called  for  in  a  case  in  which  the  forces 
require  to  be  sustained  at  the  same  time  by  "supporting'  treat- 
ment." To  borrow  an  illustration  (Billing),  the  one  is  like  taking 
part  of  the  load  from  the  cart,  the  other,  whipping  the  tired  horse 
up  the  hill. 

Personal  experience  and  judgment,  however,  are  indispensable 
to  the  application  of  these,  or  of  any  analogous  principles,  to 
cases  in  regard  to  the  management  of  which  the  profession  has 
been,  but  we  may  hope  will  not  be  always,  divided.  The  recent 
tendency  of  medical  practice  has  been  quite  too  much  in  the 
direction  of  over-stimulation. 

Depression  is  exemplified  in  the  state  produced  by — 

Severe  injuries;  e.  g.,  railroad  accidents,  extensive  burns,  etc. 

Mental  shocks;  e.  g.,  terror  or  great  grief. 

Withdrawal  of  accustomed  stimulation;  e.  gf.,  delirium  cum  tre- 

more.^ 
Intense    toxaemia;    e.  g.,    pernicious    intermittent,  etc.   (see 

above). 
Gouty  spasm,  of  the  heart  or  stomach,  etc. 

1  Unless  clear  indication  exists  for  a  surgical  operation  to  relieve  ihe  obstruction. 

2  It  is   not  intended,  of  course,  to  indicate   that  all  cases  of  delirium  tremens  ai'e 
referable  to  this  cause. 


AN  A  LKPTICS.  157 

Stiniulalion  by  alcohol,  ammonia,  ether,  opium,  camphor,  tur- 
pentine, capsicum,  etc.,  is  needed,  with  greater  or  less  urg(!ncy, 
and  in  larger  or  smaller  doses,  in  all  of  these  conditions  ;  always 
bearing  in  mind  tlie  prol»atiility  of  7-eac<(0*i  and  avoiding,  as  far  as 
possible,  tlie  exaggeration  of  this  reaction  into  fever. 

Dr.  Lidell'  remarks  that  "'the  physician's  success  in  saving  or 
prolonging  life  in  cases  of  jjulmonary  tui)erculosis,  chronic  bron- 
chitis, chronic  (jueumonia,  chronic  pleurisy,  chronic  abscess,  ver- 
tebral caries,  chlorosis,  leuktemia,  scrofulous  adenitis,'^  ague 
cachexia,  syphilitic  cachexia,  infantile  marasmus,  and  many 
other  debilitating  diseases,  will  largely  depend  upon  his  ability 
to  prevent  the  occux-rence  of  thrombosis  '  in  some  part  of  the 
venous  system."  Ammonia  is  urged  as  meetuig  this  indication, 
as  well  as  that  of  pure  stimulation. 

The  prostration  of  t)/))hus  fcvn\  in  a  majority  of  cases  {rtot  in 
all)^  and  that  of  typhoid  fevrr,  in  a  minority  of  cases,  requires 
especially  after  the  height  of  the  fever  has  passed,  alcoholic  stimu- 
lation, as  well  as  sui»port  by  concentrated  liquid  nutriment  (beef- 
tea,  milk),  at  short  intervals. 

The  instances  of  these  fevers  afford  a  sort  of  intermediate 
gradation  between  what  I  have  called  acute  and  chronic  debihty. 

In  regard  to  the  latter  (the  debility  of  convalescence,  chronic 
disease,  etc.),  certain  principles  are  agreed  upon  b}^  all  physicians, 
on  the  ground  of  experience,  confirmed  by  the  deductions  of  phys- 
idlogical  science.  We  shall  ilrst  brieily  consider  some  of  these, 
and  then  one  or  two  debatable  points  akin  to  those  already 
alluded  to. 

The  two  most  important  and  familiar  results  of  clinical  experi- 
ence in  the  treatment  of  debility,  are,  the  superiority  of  the  pure 
vegetable  bitters  in  stomachic  and  digestive  weakness,  and  of  iron 
in  anaemia  (spanremia).  The  influence  of  qninia  andcinchonia 
in  nervous  debility  is  equally  assured.  The  confidence  of  many 
physicians  is  strongin  the  utility  of  the  mineral  tonics  (zinc,  cop- 
per, arsenic,  and  silver  salts) '  in  debility  with  nervous  sjrmptoms ; 
e.  (/.,  chorea,  hysteria,  etc.  I  believe  this  confidence  to  be 
deserved,  to  a  considerable  extent ;  but  some  of  the  diseases  in 
which  these  medicines  are  given  (e.  g.,  epilepsy)  will  in  many 
instances  baffle  all  treatment.  The  use  of  strychnia  in  certain 
cases  of  paralysis  is  also  well  established  ;  although  requiring 
much  care  and  discrimination.  Some  practitioners  (Coujiland, 
Gulstonian  Lectures,  1881)  make  considerable  use  of  arsenic  in 
obstinate  anajmia. 

Cod-liver  oil  holds,  at  the  present  time,  a  very  high  place  in 
the  list  of  analeptics.  All  medical  observers  are  not  of  one 
opinion  in  regard  to  its  value  ;  but  most  of  them  believe  it  (on 
the  basis  of  experience  in  practice)  to  be  the  best  and  most 
reliable,  whei'e  it  is  tolerated,  of  all  recuperative  medicines,  not 
only  in  consumption,  but  in  other  wasting  diseases. 

The  theory  of  the  mode  of  action  of  cod-liver  oil  as  an  analeptic 

1  Am.  .Tournal  of  Med.  Sciences,  July,  1874. 

^Glandular  inflammation.  a  Coagulation  of  blood  in  a  vein. 

*  Salts  of  mnnt^nnrxe  (^ phosphate  and  sulphate)  are  valued  by  some  physicians  as  very 
aseful  in  ansemia  and  debility. 

14 


158  GENERAL    THERAPEUTICS. 

is  an  interesting  subject.  Dr.  Bennett's  view  of  phthisis  was 
that  the  error  of  liseinatosis,  from  which  tubercle  results,  consists 
in  an  excess  of  albumen  in  the  blood,  with  a  deficiency  of  oil ;  so 
that,  in  the  process  of  cell-formation,  the  first  step  of  which  is 
believed  (Ascherson)  to  be  the  investment  of  oil  globules  with  albu- 
minous envelopes^  an  imperfection  exists  fatal  to  the  subsequent 
development  of  the  cell,  and  ohliging  it  to  abort.  But  the  debili- 
tation of  the  digestive  and  assimilative  functions  in  phthisis  renders 
it  impossible  by  ordinary  food  to  supply  the  desiderated  oleagin- 
ous matter  to  the  blood.  Cod-liver  oil  is  fatty  matter  which,  by 
the  assimilating  action  of  the  liver,  following  the  process  of 
digestion,  is  prepared  for  immediate  absorption  and  appropriation 
by  the  blood,  for  purposes  of  nutrition.  This  rationale  of  its 
influence  is,  although  not  demonstrable,  much  more  probably 
correct  than  that  which  refers  it  to  the  presence  of  iodine,  phos- 
phorus, or  any  other  special  ingredients  which  it  may  contain. 
Allusion  to  the  more  lately  introduced  dugong  oil  (Holt),  shark 
oil,  etc.,  would  be  more  proper  in  connection  with  the  subject  of 
materia  medica  than  here. 

The  phosphates  and  h3rpophosphites  have  attracted  a  great 
deal  of  attention.  I  do  not  consider  the  question  settled  as  yet, 
as  to  their  comparative  value.  My  impression,  however,  is,  that 
the  phosphate  of  iron  is  the  best  of  them  all,  and  that  they  will 
be  found  secondary  and  inferior  to  cod-liver  oil.  Still,  a  combi- 
nation of  hypophosphites  often  proves  useful  in  improving  appe- 
tite and  digestion. 

Within  a  few  years  renewed  attention  has  been  given  (Gubler, 
Hammond,  Baumetz,  S.  E.  Percy,^  Eouth)  to  the  effects  of  phos-' 
phorus  (not  in  the  state  of  phosphoric  acid)  in  exhaustion  of  the 
brain  and  nervous  system ;  as,  e.  g.,  from  over  brain-work  or 
worry,  or  from  venereal  excesses.  Chemical  analysis  shows  a 
diminished  amount  of  phosphorus  in  the  brains  of  aged  people, 
and  still  more  in  those  of  idiots.  There  is  reason  to  believe  that 
it  is  also  lessened  especially  in  cases  of  softening  of  nerve  centres. 
Phosphorus  is  safe  in  doses  of  /g  grain,  in  oil  or  in  powder  with 
some  farinaceous  substance.^  Amorphous  phosphorus  is  the 
least  irritating,  and  therefore  most  safe.  Phosphide  of  zinc  is 
often  given,  in  pill,  in  gr.  -^^  to  gr,  }  doses. 

What  is  the  proper  place  of  alcoholic  beverages  or  prepara- 
tions in  the  treatment  of  chronic  debility,  such  as  that  of  phthisis, 
etc.  ? 

This  important  question  opens  a  discussion,  only  the  main 
elements  of  which  can  be  noticed  in  this  work. 

In  the  first  place,  the  theory  of  the  action  of  agents  called 
stimulants  was  formerly  almost  always  misstated  in  authorita- 
tive treatises.  It  lias  been  commonly  laid  down  that  "one  of 
the  laws  of  all  stimulation,  whatever  may  be  its  degree,  is,  that 
it  is  followed  by  a  defjression  proportionate,  at  least  approxi- 
mately, to  the  previous  exaltation  of  the  function  or  functions 
excited." 

The  true  law  is  this  :  that  all  stimulation  which  is  excessive 

1  Prize  Essay  on  Phosphorus,  etc.,  Trans.  Am.  Med.  Assoc.,  1872. 
»  See  Routh  on  Overwork  and  Premature  Decay,  etc.,  1873. 


ATiCOTTOT..  159 

is  followed  by  a  depression  corresponding  to  the  excess;  while  all 
that  merely  excites  any  function  up  to  par  (to  use  a  familiar 
expression),  i.  r.,  to  or  toward  its  normal  activity,  does,  so  far, 
only  good,  with  no  rrsnUiiuj  dcl)ilitation,  however  it  may  fail, 
from  want  of  other  conditions,  to  sustain  the  organ  or  system 
at  the  point  desired.  To  deny  this  would  be  to  ignore  some  of 
the  most  obvious  physiological  facts.  Heat  is  a  stimulant  to  life 
force  ;  oxygen  to  all  th(^  active  functions  ;  blood  is  an  excitant  as 
well  as  fofxl  to  all  the  tissues  it  reaches  ;  and  all  those  impres- 
sions upon  the  exterior  of  the  body  which  give  rise  to  instinctive 
or  automatic  actions  are  stimulants,  without  any  necessary 
ulterior  depression.  Nor  do  I  see  how  the  use  of  stimulants  in 
any  supposable  case  of  disease  could  be  rationally  justified,  if  we 
practicdllji  admitted  the  force  of  the  law  as  above  stated  ;  sin(;e, 
if,  after  every  dose  of  aia  excitant,  the  patient  should  sink  as  far 
hclow  the  condition  for  which  he  was  treated,  as  the  intended 
remedy  raised  him  for  the  moment  above  it,  of  course  a  mere 
osciUation,  and  no  advantage,  must  be  the  result.^ 

This,  however,  is  theory,  which  has  not  largely  governed 
practice  on  this  subject.  Another  interesting  physiological 
question — "  does  alcohol  contribute  to  the  material  or  to  the 
force  of  the  economy,  or  only  excite  some  of  its  organs  to 
exhaustive  action?" — has  been  the  topic  of  able  and  learned 
disquisitions.  I  venture  the  opinion  that  it  may  do  either  of  the 
three,  or  neither^  according  to  the  circumstances  and  the  quantity 
of  its  administration.  When  there  is  scarcity  offood^  or  difficulty 
of  digestion,  alcohol  may  contribute  to  the  needed  material;  its 
carbon,  hydrogen,  and  oxygen  going  to  repair  the  adipose  tissue 
at  least,  and  to  economize  albuminous  substances.'^  When  there 
is  excessive  exertion,  alcohol  may  sustain  the  flagging  forces  of  the 
system.  When  given  in  viere  excess,  as  with  the  intemperate,  it 
excites  to  exhaustive  action,  organic  if  not  motor ;  even  when 
the  bloated  body  shows  increase  in  quantity  of  material,  its  quality 
being  more  or  less  degenerate. 

Parkes,  Richardson,  and  others  have  shown  that  alcohol,  given 
during  health,  produces  a  wasteful  consumption  of  force,  by  ac- 
celerating the  heart's  action. 

In  a  word,  then,  the  phrase  "accessory  food  "  is  a  happy  one. 
When  unnecessary,  as  in  full  health,  alcohol  is  injurious  precisely 
in  proportion  to  the  quantity  used  ;  and  the  same  is  true  in. 
disease,  when  the  quantity  given  is  disproportionate. 

This  is  the  important  practical  precept.  Alcoholic  stimulus 
should  never  be  taken  in  quantities  which  produce  circulatory 
or  cerebro-nervous  disturbance  or  suj^er-excitation.  If  this  rule 
be  observed,  not  only  will  it  be  a  valuable  supporting  agent  in 
phthisis  and  other  complaints,  but  no  dipjsomaniaj  (methomania) 
or  morbid  thirst  for  it  will  arrive,  thai  terrible  disease  always 
growing  out  of  excess.    Upon  this  principle,  in  the  use  of  alco- 

1  Some  recent  writers  have  ahjured  the  term  "  stimulation,"  and  the  idea  commonly 
attached  to  it,  altogether;  particularly  as  applied  to  the  effects  of  alcohol.  Although 
made  excusable  by  an  error  in  the  now  prevailing  vaso-motor  physiology,  this  innova- 
tion in  the  use  of  language  tends  only  to  confuse  the  judgment  and  paralyze  practice. 

-  Dr.  Wilks,  of  Guy's  Ho.spital,  London,  has  given  carefully-obtained  evidence  that 
alcohol,  under  some  circumstances,  acts  as  food.    See  Lancet,  Jan.  27,  1872. 


160  GENERAL    THERAPEUTICS. 

holic  beverages  in  cases  of  ordinary  debility,  tlie  common  table 
doses  are,  medicinally  speaking,  too  large. 

Alcohol,  in  advanced  or  advancing  consumption,  in  low  fever, 
and  in  other  analogous  cases,  when  used  in  due  proportion,  is 
useful — 

1.  By  its  direct  excitanl/supporting  power. 

2.  By  aiding  the  enfeebled  stomach  to  digest  a  larger  supply 
of  food. 

3.  By  tending  to  retard  tissue-metamorpliosis. 

This  last  action  is  one  which  alcohol  has  been  shown  (Booker, 
Hammond)  to  have,  under  some  circumstances,  at  least,  in  com- 
mon with  other  agents,  used  as  medicines  or  luxuries  ;  coffee, 
tea,  morphia,  quinia,'  etc.  I  have  alluded  to  it  in  our  classifica- 
tion of  remedies,  under  the  head  of  "  economic  medicines." 

It  is  not  supposable,  however,  that  the  retardation  of  the 
change  of  tissue  in  the  body  is  always  beneficial.  It  may,  espe- 
cially in  febrile  disease,  when  accumulation  of  effete  matter  in 
the  blood  and  organs  is  a  present  evil,  be  injurious. 

It  is  probable,  however,  that  in  low  fevers,  when  oxidation  is 
going  on  excessively,  alcohol  yields  carbon  and  hydrogen  as  fuel  for 
the  "•combustion"  which  takes  place  under  the  depression''*  of 
life-force  ;  thus  economizing  the  materials  of  the  blood  and  tis- 
sues. This  may  explain  the  entire  absence  of  "toxic"  effects 
of  alcohol  when  given  in  typhus,  in  regulated,  but  often  consid- 
erable quantities.  When  more  is  given  than  can  he  consumed  by 
oxidation.,  then  symptoms  of  alcoholism  occur. 

The  lowering  of  temperature  under  the  use  of  small  or  mod- 
erate doses  of  alcohol  in  low  fevers,  may  be  accounted  for  in  two 
ways :  1,  by  its  combustion  generating  less  heat  than  that  of  other 
materials  in  the  blood  and  tissues  whose  place,  in  oxidation,  it 
may  take  ;  2,  by  its  energizing  influence  upon  the  ganglia,  through 
which  the  vital  control  over  excessive  waste  and  combustion  may 
be  restored  or  promoted. 

Admitting,  then,  the  frequent  utility  of  alcohol,  we  are  pre- 
pared, most  of  all  from  clinical  observation,  to  condemn  without 
hesitation  or  qualification  the  practice  introduced  by  the  late  Dr. 
Todd,  of  London  (foreshadowed  by  that  of  the  famous  Dr.  Brown 
of  the  last  century),  of  giving  alcohol  as  the  remedy  or  proper 
medicine  " for  all  acute  diseases."  Enough  for  our  present  pur- 
pose to  cite  some  impartial  testimonies  as  to  the  results  of  that 
practice. 

1.  The  physician  whom  Dr.  Todd  intrusted  with  the  task  of 
analyzing  his  own  records  of  hospital  practice^  asserts,  that  the 
mortality  from  fever  in  the  hospital  attended  by  Dr.  Todd  was  in 
a  marked  degree  greater  than  that  of  any  other  fever  hospital  in 
Great  Britain. 

2.  Statistics  of  the  London  Hospital*  more  recently  published, 

1  Kerner,  Eanke,  and  Strassburg  have  shown  that  quininization  diminishes  by  one- 
half  the  excretion  of  urea  and  uric  acid. 

2  Lowering  of  vital  energy  being  attended  by  increased  activity  of  ordinary  chemical 
change. 

3  British  and  Foreign  Medico-Chirurg.  Review,  October,  1860,  p.  331. 
i  British  Med.  Journal,  Dec.  9,  186£t 


STIMULTSM,  161 

show  a  large  Increase,  since  1858,  in  the  use  of  stimulants  in  that 
hospital,  and,  with  it,  a  closely  coincident  ratio  of  increase  in  mor- 
tality. 

3.  Drs.  Gairdner'  and  Kussell  have  shown,  in  the  Glasgow 
Fever  Hospital,  that  even  typhus  may  be  treated,  with  excellent 
results,  almost  entirely  withoiit  alcohol. 

Stimulism,  as  we  may  call  the  theory  and  practice  of  Dr. 
Todd,  since  followed  by  many  others,  confomids  three  distinct 
propositions  :  1.  That  all  disease  is  debility;  2.  That  all  debility 
should  be  treated  by  the  use  of  stimulants ;  3.  That  alcohol  is 
always  the  best  stimulant.  Granting,  with  some  qualification, 
the  hrst  of  these,  wc  emphatically  deny  the  truth  of  the  second 
and  third.  It  is  a  practice  which,  like  many  other  specialisms., 
will  have  its  day.  It  is  already  subsiding  in  most  places.  Says 
Dr.  J.  Matthews  Duncan,'^  "  This  practice  was  derived  from 
London,  and  I  hope  London  will  have  the  honor  of  putting  an 
end  to  it."  8ir  W.  Jenner's  rule  in  treatment  of  typhoid  fever* 
may  well  have  a  wider  extension:  ''to  abstain  from  giving 
alcohol  if,  in  the  case  before  me,  I  douht  the  wisdom  of  giving 
it ;  and  when  there  is  a  question  of  a  larger  or  smaller  dose,  I, 
as  a  rule,  i)rescribe  the  smaller."  In  a  large  "Temperance  Hos- 
pital" in  London,  alcohol  is,  practically,  omitted  in  the  treat- 
ment of  all  cases  of  disease.  This  is  an  extreme  which  my  own 
experience  agrees  with  that  of  the  profession  generally  in  not 
believing  to  be  a  safe  example  in  therapeutics,  nor  one  demanded 
by  the  interests  of  temperance.  When  used  with  proper  judg- 
ment and  caution,  alcohol  may  be  administered  with  as  little 
danger  of  subsequent  habits  of  excess  as  any  other  powerful  med- 
icine.    But  such  caution  is  of  great  consequence. 

The  following  classification  of  the  "genuine  effects  of  stimula- 
tion," when  properly  used  as  to  time  and  dosage  (remembering 
the  often  opposite  effects  of  small  and  large  d.oses),  is  from  Anstie.* 

"I.  Relief  of  pain.  II.  Removal  of  muscular  spasm,  tremor, 
or  convulsion.  III.  Reduction  of  undue  frequency  of  the  cir- 
culation. lY.  Reduction  of  excessive  secretion.  Y.  Removal 
of  general  debility,  or  of  special  fatigue  of  muscles,  brain,  or 
digestive  organs.  Yl.  Removal  of  delirium  or  maniacal  excite- 
ment, and  production  of  healthy  sleep.  YIL  Support  of  the 
organism  in  the  absence  of  ordinary  food.  YIII.  Local  increase 
of  nutrition  where  this  is  deficient." 

From  the  same  writer  comes  also  the  following  terse  summary 
of  the  stimulating  agencies  most  available  therapeutically. 

"1.  Quickty  digested  and  nutritious /ood.  2.  Opium  in  doses 
of  one  or  two  grains;  or  morpjhia  (sulphate,  etc.)  a  quarter  to 
half  a  grain.  3.  Carbonate  and  chloride  of  ammonium  in  doses 
of  five  and  ten  grains  respectively.  4.  Alcohol,  in  doses  just  too 
small  to  produce  flushing  of  the  face  or  sweating  of  the  brow.*" 
5.  Chloroform,  inhaled  (in  the  proportion  of  about  two  per  cent, 
to  the  bulk  of  atmospheric  air)  for  a  short  time  ;  or  taken  inter- 

1  British  Med.  Journal,  Aug.  22,  1868.        2  Lancet,  Oct.  30, 1880. 

3  Ibid.,  Nov.  15,  1879.  *  On  Stimulants  and  Narcotics,  pp.  112,  113. 

5  It  is  singular  that  Headland  (On  the  Action  of  Medicines,  last  edition)  does  not 
include  alcohol  in  his  list  of  stimulants.    It  is,  with  him,  an  "  inebriant  narcotic." 

14*  L 


162  GENERAL    THERAPEUTICS. 

nally,  in  doses  of  a  few  drops,  6.  Certain  fetid  gum  resins.  7. 
Many  aromatic  volatile  oils.  8.  The  bitters,  pure  and  aromatic. 
9.  Counter-irritation,  as  it  is  called  ;  stimulation,  as  it  should  be 
termed,  through  ttie  skin." 

Hypodermic  injection  of  powerful  stimulants  is  sometimes  used 
in  cases  of  threatening  collapse.  Ether^  has  been  so  employed, 
15  drops  being  thrown  in  under  the  skin  at  a  time.  Ammonia 
has  been  similarly  administered,  in  so  strong  a  solution  as  equal 
parts  of  aqua  amraonise  and  water  ;  a  fluidrachm  being  injected 
at  once^  into  a  vein.  Whisky  or  brandy  may  be  resorted  to 
under  like  circumstances  ;  when  (for  example,  from  exhausting 
hemorrhage)  life  is  endangered  by  prostration  not  reached  by 
stimulants  administered  by  the  mouth  or  rectum. 

Under  the  now  accepted  opinion  that  digitalis  is  a  "heart 
tonic,"  it  (or  digitalin)  is  sometimes  used  by  hypodermic  injec- 
tion, in  cases  of  "flagging  heart ;  "  and  atropia  as  a  stimulant  to 
the  respiratory  function. 

Dr.  Karel,  of  St.  Petersburg,  within  a  few  years,  obtained  the 
attention  of  the  profession  to  the  treatment  of  dyspepsia,  chronic 
nervous  affections,  etc.,  by  an  exclusive  diet  of  skimmed  milk.  Dr. 
Donkin  followed  him,  giving  in  Bright's  disease  and  other  chronic 
diseases  six  or  seven  pints  of  skimmed  milk  daily,  for  weeks 
together,  without  any  other  food.  Dr.  S.  Weir  MitchelP  reports 
favorably  of  the  alterative  influence  of  this  treatment  in  obsti- 
nate disorders  of  the  stomach.  He  begins  with  one  or  two  table- 
spoonfuls  of  the  milk  on  rising,  and  every  two  hours  through  the 
day.  Increasing  the  quantity  in  a  few  days,  the  maximum  amount 
of  two  quarts  daily  is  mostly  attained  without  great  inconven- 
ience, although  some  long  constantly  for  other  food.  I  cannot 
see  anythiug  in  this  practice  but  a  purely  empirical  dernier  ressort 
in  troublesome  cases  of  chronic  disease.  As  such,  however,  it  is 
now  on  trial  by  many  physicians.  My  experience  convinces  me 
that,  in  ninety-nine  cases  in  a  hundred,  unskimmed  is  better  than 
skimmed  milk,  for  the  sick  or  well.  In  diabetes  mellitus,  however, 
skimmed  milk  may  be  preferred. 

Desiccated  blood  (Le  Bon,*  1875)  is  said  to  be  capable  of  skil- 
ful preparation  so  as  to  preserve  its  hoemoglobin,  and  to  answer 
a  good  purpose  as  a  recuperant.  Dr.  Andrew  Smith,  of  New 
York,  and  others  report  favorably  of  its  action  in  anaemic  cases. 

The  subject  of  the  treatment  of  debility,  acute  and  chronic, 
must  not  be  dismissed  without  one  further  remark,  upon  the  im- 
portance of  rest  in  cases  of  exhaustion  from  over-exertion.  The 
popular  truism,  that  exercise  is  beneficial  to  health.,  has  been  often 
abused  by  applying  it  universally  to  invalids  or  valetudinarians. 

The  one  remedy  for  the  immediate  effects  of  over-exertion  is  abso- 
lute and  prolonged  repose. 

The  time  required  for  recuperation,  after  cerebral  over-fatigue, 
may  be  counted  rather  by  months  than  by  weeks  or  days  ;  and  it  is 
quite  possible  for  irreparable  mischief  to  be  done  to  the  brain  or 

1  Verneuil,  Journal  de  Med.  et  de  Cliirurg.  Pratiques,  March,  1877. 

2  Griswold,  N.  Y.  Med.  Record  June  7,  1879. 

3  Phila.  Medical  Times,  Oct.  15,  1870,  et  seq. 

*  Comptes  Rendus,  1875.    See  Journal  de  Thgrapeutique,  Nov.  25, 1880. 


CALMATIVE    TREATMENT.  163 

spinal  marrow  by  neglecting  too  long  the  demand  of  nature  for 
rest.  With  many  others,  the  author  must  acknowledge  indebt- 
edness to  the  late  Prof.  Jackson,  of  the  University  of  Pennsylva- 
nia,  for  the  judicious  empliasis  of  his  teaching  upon  this  point. 

It  is  an  important  hygienic  and  therapeutic  law,  that  exercise, 
to  be  beneticial,  must  be  proportionate  to  the  strength  of  the 
individual ;  and  must  never  be  carried  to  the  extent  of  great 
fatigue  or  temporary  exhaustion. 

Calmative  treatment  has  always  been  regarded  as  of  impor- 
tance in  allections  of  the  nervous  system ;  not  only  for  the  relief 
of  suffering,  but  to  arrest  the  waste  of  irritation.  Opium,  cam- 
phor, valerian,  and  assafoetida  are  the  oldest  and  most  commonly 
appreciated  medicines  of  this  class.  Warm  and  tepid  baths  and 
ablutions,  simple  or  medicated  (especially  with  salt  or  alcohol), 
have  always  been  favorite  adjuvants. 

Bromide  of  potassium  has  come  largely  into  use  within  a  few 
years  (Locock,  1852),  as  a  sedative  to  reflex  exdtability  of  all  the 
surfaces,  or  rather  of  the  centres,  of  the  body.  In  sleeplessness, 
ejnlepsi/,  hysteria,  and  spermatorrhoea,  it  has  seemed  to  be  particu- 
larly valuable.  I  have  always  found  it  to  act  mildly  and  safely 
in  twenty-grain  doses.  Tliirty  or  forty  grains  at  a  single  dose 
may  be  safe  in  an  adult  generally.  Dr.  Da  Costa  has  pointed  out 
that  the  bromide  adds  to  the  beneficial  effects  of  opiates,  given 
with  or  after  it.  Bromide  of  sodium  is  very  similar  in  its  effects, 
and  agrees  better  with  some  feeble  patients.  Bromide  of  calcium 
does  not  generally  set  so  well  u^Don  the  stomach.  The  sedative 
action  of  the  bromides  when  locally  applied,  in  solution,  is  some- 
times valuable.  Bromo-camphor  (Schwartz)  is  said  to  act  as  a 
useful  calmative  in  2  to  5  grain  doses.  It  must  be  remembered, 
however,  that  the  continuance  of  any  of  the  bromides  in  large 
doses  may  cause  bromism;  a  condition  of  general  debility,  with 
abdominal  pain,  fetid  breath,  salivation,  nausea,  vomiting,  or 
purging,  an  eruption  like  acne,  anaesthesia  of  the  skin,  dilated 
pupils,  dimness  of  sight,  unsteadiness  in  walking,  drowsiness  and 
lowness  of  spirits.  Organic  disease  of  the  kidneys  is  considered 
to  contraindicate  the  use  of  the  bromides. 

Hydrate  of  chloral  has,  since  its  introduction  by  Liebreich,  of 
Berlin,  taken  a  leading  place  among  hypnotic  or  sleep-producing 
medicines.  It  appears  to  be  nearly  as  certain  in  its  action  as 
opium,  with  less  unpleasant  after  effects  ;  but  to  be  not  so  power- 
ful in  the  relief  of  pain.  As  a-xx^antispasmodic,  under  various 
circumstances,  it  has  proved  etficacious.^  Some  tendency  to 
depression  of  vital  energy  is  observable  under  the  influence  of 
considerable  doses  of  chloral  hydrate.  This  is  especially  as- 
serted as  of  importance  in  contra-indicating  its  employment 
when  the  respiratory  function  is  impaired.     What  I  have  seen  of 

1  Hydrate  of  chloral  is  soluble  in  water,  alcohol,  ether,  chloroform,  and  fatty  sub- 
stances. Dosf,  15  to  30  grains.  Much  larger  doses  are  given,  but  are  not  unattended 
by  danger.  Death  has,  in  a  number  of  instances,  followed  excess  in  its  use.  Chloral 
hydrate,  being  pungent  and  acrid,  should  be  considerably  diluted  when  taker. ;  but  tlie 
scihition  should  always  be  freshly  prepared,  as  it  does  not  keep  well.  Alkalies  are 
incompatible  with  it."  Dr.  Kidd  has  reported  its  acting  well  by  enema  when,  given  by 
the  luouth,  it  disturbs  the  feeble  stomach. 


164  GENERAL    THERAPEUTICS. 

its  use,  however,  gives  me  the  impression  that  (as  regards  small 
doses^  at  least)  the  danger  of  this  has  been  rather  over-rated.' 
Probably  the  chief  danger  attends  its  depressing  influence  upon 
the  heart  and  general  circulation.  Persons  habituated  to  its  use 
for  a  considerable  time  l^ave  sometimes  died  suddenly  after 
taking  not  more  than  60  or  70  grains  at  once  ;  as  if  the  vascu- 
lar (or  vaso-motor)  system  had  been  previously  enfeebled  by  it.^ 

Dr.  Edward  Hartshorne  has  found  chloride  of  ammoniimi^  in  15 
or  20  grain  doses,  to  exert  a  tranquillizing  influence  not  unlike 
that  of  the  bromides. 

Under  the  head  of  antispasmodic  calmatives  may  be  named 
nitrite  of  amyl;  the  inhalation  of  which  is  now  often  resorted  to 
for  the'  arrest  or  prevention  of  paroxysms  of  epilepsy,  angina 
pectoris,  etc.  It  must  be  used  with  care  ;  inhaling  at  first  only  a 
few  drops  at  a  time.  The  sign  of  its  action  is  flushing  of  the  face. 
It  may  be  carried  about  the  person  in  well  stopped  small  vials  ; 
each  vial  containing  not  much  more  than  a  single  dose,  as  what 
is  left  after  breathing  is  nearly  inert.  Some  practitioners,  to 
avoid  spilling,  have  the  vial  fix'st  filled  witli  cotton,  which  is  then 
saturated  with  the  nitrite.  The  dose  of  it  may  be  gradually 
increased,  when  it  is  inhaled  repeatedly. 

Jamaica  dogwood  (piscidia  erythrina)  is  one  of  the  later  narcot- 
ics, from  whose  action  upon  animals  a  useful  role  as  an  anodyne 
is  hoped  for,  but  not  yet  (1881)  safely  ascertained. 

Eri/throxylon  coca,  of  South  America,  has  been  long  known  as  a 
popularly  used  nerve-stimulant  in  its  native  country.  Although 
getting  latterly  under  trial,  its  precise  uses  in  practical  medicine 
are  not  yet  well  defined.  Its  action  is  more  like  that  of  coffee  and 
tea  than  that  of  opium.     (Dose  of  fluid  extract,  f5ss  to  f5ij-) 

Antidotal  treatment  is  a  topic  of  great  interest.  Its  idea  is 
probably  the  oldest  in  medicine.  Specifics  have  always  been 
looked  upon  as  the  magna  bona  of  therapeutical  science.  Unfor- 
tunately, however,  their  number,  instead  of  increasing,  has 
diminished  under  the  inexorable  scrutiny  of  modern  investiga- 
tion. Yet,  there  is  room  for  hope  that  they  may  again  positively 
increase,  with  the  diligent  application  of  enlarged  means  of 
observation  and  discovery. 

In  the  widest  extension  of  the  term,  antidotive  remedies  may 
be  classified  thus : — 

Positive  antidotes ;  ^         . 

Chemical  palliatives ;  '  Chemical  antidotes; 

Antacids ;  Antitoxics ; 

Antilithics,  Parasiticides. 

Constructive  antidotes ; 

Antiperiodics ;  Antiscorbutics. 

Antisyphilitics  ; 

1  Ordylowski  (Gazette  des  Hopitaux,  Aug.  28, 1880)  asserts  that  in  a  considerable  num- 
ber of  eases  of  phthisis,  doses  of  15  to  30  grains  of  chloral  at  bedtime  promoted  rest  and 
strength,  -without  any  bad  symptoms  in  any  of  the  cases. 

2  A  prominent  symptom  of  chloral  poisoning,  however,  is  stupor  (coma).  See  an 
article  by  Dr.  H.  H.  Kane,  in  N.  Y.  Medical  Record,  Dec,  1880. 


ANTIDOTAL    TREATMENT.  165 

Tentative  antidotal  remedies ; 

Antiarth  ritics;  Antiseptics; 

Antirheumatics ;  Antiziimotirs. 

The  familiar  use  of  antacids  as  palliatives  in  dyspepsia,  etc., 
needs  no  remark. 

Nor  have  we  occasion  to  dwell,  here,  upon  antilithics ;  i.  e., 
solvents  for  urinary  solids,  prescribed  on  chemical  principles ;  as 
alkalies  for  excess  of  uric  acid  or  the  urates,  mineral  acids  for 
excess  of  phosphates  or  oxalates. 

The  subject  of  chemical  antidotes  for  poisons  belong  to  Toxi- 
cologi/.     (See  Part.  II.) 

Anthelmintics  are  best  treated  of  in  the  department  of  Prac- 
tice of  Medicine.     (Part  II.) 

Antipsorics,  or  specific  remedies  for  scabies  (itch),  arc  repre- 
sented generally  by  sulphur;  which,  although  not  at  all  the  only 
agent  capal)le  of  destroying  the  morbific  acarus  (sarcoptes),  is  the 
most  cimvenient.  Other  cutaneous  parasites  (nosophyta)  are 
also  destroyed,  but  with  less  certainty,  by  preparations  of  mer- 
cury, etc.,  called  parasiticides. 

Of  "constructive  antidotes,"  the  most  important  are  the  alka- 
loids of  cinchona,  applied  to  the  treatment  of  malarious  affections 
(antiperiodics).  Medical  men  are  divided  upon  the  question 
whether  quinia  arrests  intermittent  fever,  etc.,  by  antagonizing 
(chemically)  the  organic  poison  itself  in  the  system,^  or  (physi- 
ologically) by  caus^ing  such  an  opposite  impression  upon  the 
nervous  centres  as  is  capable  of  subverting  the  condition  on  which  \ 
the  periodical  or  paroxysmal  affection  depends.  The  last  is  the 
prevailing  view.  But,  in  either  aspect,  the  cure  of  autumnal 
fevers  and  allied  affections  occurring  under  malarial  influence 
(neuralgias,  etc.),  by  cinchonization,  is  properly  called  specific 
treatment ;  as — 

1.  No  other  remedies  (yet  discovered)  have  the  same  power. 

2.  These  remedies  have  no  such  control  over  any  other  diseases 
{e.  g.,  typhus  and  typhoid  fever,  yellow  fever). 

The  second  proposition  is  asserted  with  positiveness,  notwith- 
standing the  now  common,  but  still  experimental,  use  of  quinine 
in  full  doses  in  typhus  and  typhoid  fever,  and  its  frequent  admin- 
istration in  yellow  fever. 

Dr.  E.  B.  Baxter,  of  London  {Practitioner,  Nov.,  1873),  reports 
a  series  of  experiments  showing  the  antiseptic  power  of  quinia, 
quinoidine,  cinchonidine,  and  cinchonia ;  the  comparative  action 
of  these  alkaloids  in  this  respect  (and  their  control  over  the 
migratory  movements  of  the  colorless  blood-corpuscles),  being 
relatively  proportionate  to  their  antiperiodic  and  curative  power. 
The  power  of  quinine  to  destroy  minute  fungoid  vegetative 
organisms  has  been  asserted  by  several  observers.  So  has  that 
of  the  active  principle  of  eucalyptus  globulus.  This  accords 
especially  with  the  "fungous"  or  "disease  germ"  theory  of 
malarious  causation. 

In  stating  that  no  other  medicines,  yet  discovered,  have  the 

1  Bence  Jones  found  in  human  blood  a  fluorescent  material,  in  small  amount,  not 
improl)al)ly  supposed  to  be  identical  with  quinia;  Drs.  E.  Rhoads  and  VV.  Pepper  also 
ascertained  a  deliciency  of  this  "animal  quinoidine"  to  exist  inpatients  suffering  under 
malarial  disease.— See  Penna.  Hospital  Eeports,  1868,  p.  269. 


166  GENERAL    THERAPEUTICS. 

same  power,  I  mean,  to  a  degree  or  with  a  certainty  at  all  com- 
parable to  that  of  the  cinchonic  alkaloids.  The  nearest  approach 
to  this  is  afforded  by  arsenic  and  the  sulphites. 

It  is,  however,  a  remarkable  and  important  fact,  that,  when 
the  recurrence  of  the  paroxysms  of  intermittent  fever  has  been 
allowed  for  a  long  period  (ckronic  intermittent),  and  the  system 
of  the  patient  has  become  debilitated  and  anaemic,  quinine  will 
only  interrupt,  but  will  not  cure  the  disease.  Iron  is,  then,  the 
remedy. 

Opinion  is  divided  as  to  the  value  or  necessity  of  mercury  as 
an  antisyphilitic.  In  the  primary  disease  I  am  a  full  believer  in 
its  importance ;  against  which  its  frequent  abuse  furnishes  no 
argument.  In  secondary  syphilitic  affections,  especially  syphilitic 
rheumatism,  iodide  of  potassium  also  exhibits  decidedly  specific 
powers. 

Antiscorbutics  are  most  valuable  as  preventives  of  scurvy ;  but 
will  promptly  relieve  it,  also,  when  it  has  occurred.  All  fresk 
vegetables  belong  prominently  to  this  class  ;  certain  plants  not 
so  used,  as  the  cactus  opuntia,  are  included  in  it ;  the  juice  of 
lemons,  limes,  etc.,  is  of  service  for  the  same  end,  and  the  neu- 
tral salts  of  potassium  have  been  largely  employed,  with  variable 
results. 

Tentative  antidotal  treatment — for  diseases  in  which  there  is 
evidently  (as  a  part,  at  least,  if  not  the  primary  part  of  the 
malady)  humoral  disorder,  such  as  gout,  rheumatism,  the  exan- 
themata, etc.  — affords  a  large  field  for  study  and  ratiocination. 
The  positive /acis,  so  far,  are  few;  the  hypotheses,  legion. 

In  gout,  colchicum  has  long  held,  deservedly,  a  high  place,  as 
either  an  eliminative  or  an  antidotal  remedy.  Most  observers  have 
given  it  the  first  title  ;^  Dr.  Garrod's  experiments  induced  him  to 
prefer  the  idea,  if  not  the  phrase  of  the  latter.  Alkaline  salts  of 
organic  acids,  as  bicarbonate  of  potassium,  sodium,  or  lithium 
(Garrod),  or  tartrate  of  potassium  and  sodium,  and  the  alkaline 
earth,  magnesia,  have  also  a  large  share  of  confidence  in  the 
treatment  of  gout.  Experience  satisfies  me  that  this  confidence 
is  well  founded.  After  all,  however,  so  incomplete  is  any  curative 
plan  as  yet  devised,  that  a  large  margin  is  left  for  patience  and 
opium. 

The  same  is  true  of  rheumatism;  especially  in  its  distinctive 
form,  of  acute  articular  rheumatism,  or  rheumatic  fever.  Colchi- 
cum has  been  here  also  much  given ;  but  in  the  absence  of  the  gouty, 
diathesis,'^  hereditary  or  acquired,  it  will  often,  if  not  generally,  dis- 
appoint.  Alkaline  salts  are,  with  many,  the  favorite  tentative 
anti-rheumatics.     Lemon-juice   also  has  been  freely  employed. 

1  Colchicum  has  heen  shown,  by  Krahmer  and  Hammond  (Proceedings  of  Biological 
Department  of  Acad,  of  Nat.  Sciences  of  Philadelphia,  Nov.  1st,  1857),  to  increase  the 
amount  of  the  solids  of  the  urine  more  decidedly  than  any  other  vegetable  diuretic. 

2  (iarrod  insists  on  the  diagnostic  importance  of  the  uric  acid  test  for  gout.  It  is  easily 
applied,  as  follows :  Take  about  f5jss  of  the  serum  from  a  blister,  or  from  the  blood 
drawn  by  venesection  or  cupping,  and  place  it  on  a  flat  dish  or  watch-glass.  Add  to 
this  fifteen  drops  of  acetic  acid,  and  place  in  it  two  or  three  threads  of  cotton.  Allow 
the  glass  to  stand  in  a  warm  room  for  one  or  two  days,  to  evaporate.  If  the  cotton 
fibres  be  then  removed  and  examined  microscopically  with  an  inch  object-glass,  they 
will  be  found,  if  the  serum  contained  uric  acid,  to  be  covered  with  its  crystals,  arranged 
somewhat  as  the  crystals  of  sugar-candy  form  on  a  string. 


SULPHITES.  167 

Phosphate  of  ntnmonium  was  for  a  hv'wf  timo  in  vogue.  Certain 
enfeebled  cases,  with  free  perspiration,  will  recover  speedily 
und(U'  quininiz<(li(in.  Ikil  in  all  these  modes  of  treatment  there 
is  no  spccijir  certainty.  Of  projyi/Uiinin,  as  a  remedy  for  rheu- 
matism, I  liave  had  some  experience,  and  liave  found  no  basis  for 
a  favorable  opiniim.  First  employed  by  Awenarius,  of  JSt.  Peters- 
hurg,  Drs.  (raston,  Diijardin  Beaumetz,  and  Besnier  have  reported 
favorably  of  this  remedy.  Dr.  Da  Costa'  has  obtained  good  results 
with  bromide  of  annnomum.  .Strieker,  in  1876,  asserted  rapid 
cures  with  saliajUc  acid.  Since  then,  Traube,  S6e,  Broadbent, 
Machigan  and  many  others  have  obtained,  by  their  published 
results,  the  general  confidence  of  the  profession  in  its  value. 
(See  l{hcum<(tism,  Part  II.)  As  it  is  capable  of  causing  death 
when  used  in  excess,  moderation  in  dosage  is  necessary  with  it. 

Chronic  rheumatism  is  not  satisf\ictorily  shown  to  be  a  humoral 
disease.  Except  in  its  si/'philitic  form,  when  iodide  of  potassium 
will  always  relieve  it,  there  is  no  specific  for  what  is  commonly 
known  as  chronic  rheumatism.  Of  all  medicines,  I  have  found 
oil  of  cajuput  (in  5  to  10  drop  doses)  do  the  most  in  mitigation  cf 
its  pains.  Oil  of  turpentine  is  a  more  generally  used  remedy  for 
the  same  purpose,  and  one  often  serviceable.  The  explanation 
of  the  action  of  these  oils  in  such  cases  is  very  obscure  and  doubt- 
ful. Iodide  of  potassium,  also,  is  largely  given  for  chronic 
rheumatism.  In  syphilitic  rheumatism,  it  is  absolutely  a  specific 
remedy. 

In  the  management  of  the  zymotic  aflfections,  the  only  great 
triumph  of  medical  art  has  been  one  of  prevention.  Vaccination 
afibrds  an  instance  of  control  over  one  of  the  most  destructive  and 
loathsome  of  pestilences,  by  the  interference  of  the  physician.  As 
to  the  treatment,  even  of  small-pox^  itself,  when  it  has  occurred, 
and  of  scarlet  fever,  measles,  chicken-pox,  hooping-cough,  and 
mumps,  we  are  forced  to  confess  our  powerlessness,  except  to  con- 
duct the  case,  by  the  aid  of  palliative  measures,  to  its  natural 
and  spontaneous  termination. 

This  is  equally  true  of  yellow  fever.  There  is  no  specific  yet 
known  for  this  terrible  disease.  It  is  to  be  palliated,  as  it  cannot 
he  cut  short. 

Nor  have  we  any  specific  for  epidemic  cholera.  Antispasmodics, 
at  very  short  intervals  of  administration,  and  ice,  with  free  ex- 
ternal stimulation,  will  conduct  many  cases  to  a  successful  close  ; 
but  this  is  not  antidotal  treatment. 

In  the  medication  of  zymotic  atiections  having,  as  a  local  symp- 
tom, infiammation  of  the  mucous  membranes,  with  unusual 
tendency  to  (septic)  decomposition  or  disorganization — e.  g., 
scarlatina,  diphtheria,  and  pycemia — chlorate  of  potassium  and 
other  preparations  of  chlorine,  as  tincture  of  chloride  of  iron, 
have  achieved  a  very  widespread  reputation.  Benznate  of 
sodium  has,  of  late,  with  some,  claimed  a  share  of  the  same  con- 
fidence. 

The  tincture  of  the  chloride  of  iron  appears  also  to  have  an 

1  Pennsylvania  Hospital  Reports,  18^9. 
^Sarracenia  has  proved  valueless  upon  fair  trial. 


168  GENERAL    THERAPEUTICS. 

excellent  effect  (although  we  can  hardly  call  it  antidotal)  in 
asthenic  erysipelas. 

Antidiphtheritic  power  has  been  strongly  asserted  of  lime-water^ 
locally  applied,  and  of  lactic  acid.. 

Professor  Polli,  of  Milan,  in  1864  (following  Ghaussier  and  Bielt 
of  Paris),  proposed  the  internal  use  of  the  sulphites  of  sodium, 
calcium,  and  magnesium,  in  toxsemic  diseases,  as  antizymotics 
or  antiseptics.  The  chemical  rationale  of  their  action  is  very 
plausible.  Success  has  been  asserted  ^  for  them  in  pyaemia,  scar- 
let fever,  diphtheria,  intermittent  fever,  cattle-plague,  etc.,  and 
in  glanders  in  the  horse.  As  a  tentative  practice  these  remedies 
have  seemed  wortby  of  careful  trial ;  although,  especially  in  the 
United  States  army  during  the  late  war,  the  amount  of  positive 
evidence  in  their  favor  has  not  been  very  large. 

Science  should  suggest  remedies  for  experience  to  prove;  em- 
piricism may  thus  be  made  rational,  and  rationalism  in  medicine 
may  become  practical.  Even  if  disappointment  attend  a  certain 
set  of  experiments,  such  a  trial  is  fully  justiflable  in  principle. 

The  sulphites  appear  in  the  urine  about  twenty  minutes  after 
they  are  taken  ;  also  in  the  sputa  and  saliva  ;  but  they  are  gradu- 
ally changed  in  the  system  into  sulphates.  M.  Carey  Lea,  of 
Philadelphia,  in  a  paper  published  in  1865,'^  reported  a  series  of 
careful  experiments,  in  which  he  found  evidence  that  when  a  small 
quantity  of  sulphite  or  bisulphite  of  sodium  is  taken,  less  than  a 
hundred  grains,  it  disappears  by  oxidation  in  the  system ;  but  if 
large  amounts  be  ingested,  a  considerable  portion  passes  un- 
changed in  the  urine,  and  sulphurous  acid  may  even  be  detected 
in  the  breath. 

Dr.  Polli  recommends  especially  the  sulphite  of  magnesium  as 
the  most  active  and  having  the  least  taste.  The  dose  is  fifteen  to 
thirty  grains,  in  powder,  dissolved  in  water  or  an  aromatic  vehi- 
cle, or  in  troches.  He  advises  saturating  the  system  with  the 
medicine  ;  four  or  five  drachms  daily  for  an  adult  as  a  minimum. 
Pive  to  seven  drachms  of  the  sulphite  of  sodium  are  borne  well. 
Its  long-continued  use  may  bring  on  oedema  and  diseases  of  de- 
bility ;  otherwise,  it  shows  no  special  influence  on  the  system. 

Externally^  solutions  of  the  sulphites,  especially  when  mixed 
with  a  portion  of  glycerin,  are  recommended  as  applications  to 
suppurating  surfaces,  to  sloughing  and  ulcerated  parts,  and  in 
erysipelas.  Sulphites  of  calcium  and  magnesium  are  somewhat 
caustic.  In  septaimia  from  wounds,  etc.,  Polli  administers  thirty 
grains  of  the  sulphite  of  magnesium,  every  two  hours,  internally. 

Carbolic  acid  has  also  come  under  extensive  trial,  as  an  anti- 
zymotic,  both  externally  and  internally  used.  Dr.  Shoemaker,  of 
Ohio,  amongst  others,  reports  excellent  success  with  it,  given 
internally  in  small  doses,  in  scarlet  fever.  Dr.  Ernest  Sansom^  uses 
in  scarlet  fever  and  other  allied  diseases,  the  sulpho-carbolates 
of  sodium,  potassium,  and  other  bases ;  especially  sulpho-carbo- 
late  of  sodium,  five  or  ten  grains  every  four  hours. 

iSee  Amer.  Journal  of  Med.  Sciences,  Oct.,  1863;  and  later  numbers  of  the  same 
Journal. 

2  Am.  Journ.  Med.  Sciences,  Jan.,  1865,  p.  84. 

3  Lancet,  Jan.  15,  1870. 


AliTERATIVE    TREATMENT.  169 

Silicate  of  sodium  is  asserted  by  Dubreuil'  and  Champouillon^ 
to  have  powerful  antiseptic  properties,  especially  available  locally, 
in  ozoena,  catarrhal  bronchitis  (by  atomization  of  its  solution),  and 
cytitis  with  accumulation  of  decomposing  secn^tion.  Salicylic  acid, 
iodoform,  and  bcnzoale  of  sodium  are  now  under  abundant  trial, 
in  the  treatment  of  many  disorders.  Their  antiseptic  properties 
are  only  a  part  of  those  contributing  to  their  value,  not  yet 
wholly  dcit'rnfuKHl  in  therapeutics.  Of  benzoatc  of  sodium  (rec- 
ommended byLetzerich  in  dii)hth('ria,  and  by  several  practitioners 
in  scarlet  fever)  the  minimum  dose  for  an  adult  is  five  grains ; 
some  physicians  (Klebs,  vScluiler)  give  it  or  the  benzoate  of  mag- 
nesium to  the  amount  of  5J  in  a  day.  Klebs  and  Krocsak  advise 
inhalation  of  its  solution  (from  2  to  5  per  cent,  in  water)  two  or 
three  times  daily.  Its  administration  in  phthisis  will  be  referred 
to  hereafter  in  another  place. 

One  of  the  latest  introduced  (1880)  of  anti-zymotics  is  resorcin; 
whose  eftects  have  not  yet  been  thoroughly  investigated.^ 

En  resumr,  we  may  say  that  all  endemic,  epidemic,  infectious, 
and  contagious  diseases  are  naturally  self-limited ;  and  that,  so 
far,  we  have  only  reached  a  certainly  curative  treatment  for  one 
class  —  viz.,  intermittent,  remittent,  and  pernicious  (classed  to- 
gether as  malarial)  fevers ;  and  a  preventive  treatment  for 
another,  small-pox. 

While,  therefore,  for  yelloAV  fever,  scarlatina,  pertussis,  etc., 
we  are  without  the  possession  of  any  specific  or  antidotal  treat- 
ment, the  palliative  plan  is  the  one  for  us  to  pursue.  All 
attempts,  by  violent  measures,  to  cut  short  either  of  these  diseases, 
while  they  fail  to  attain  that  object,  will  endanger  the  patient  by 
lowering  his  forces  and  thus  promoting  the  victory  of  the  depres- 
sive toxsemic  cause. 

Yet,  I  repeat,  we  are  not  to  abandon  or  reject  the  hope  that 
observation  and  cautious  experim-ent,  guided  by  the  lights  of 
advancing  science,  may  enable  us  hereafter  to  discover  remedies 
as  potent  in  the  management  and  control  of  scarlet  fever,  yellow 
fever,  and  cholera,  as  quinine  is  in  that  of  ague,  or  vaccination 
in  the  prevention  or  salutary  modification  of  small-pox. 

Alterative  treatment  is  distinguished,  in  our  classification,  it 
may  seem  arbitrarily,  from  the  antidotive.  All  antidotes  may  be 
said  to  be  alterative,  but  all  alterative  medicines  are  not  anti- 
dotal ;  as  the  latter  expression  implies  at  least  the  iwohahle,  if 
not  the  known  existence  of  a  material  cause,  against  which  the 
antidote  is  to  act.  Yet  the  distinction  is  not  one  upon  which  we 
can  insist,  although  it  appears  convenient. 

The  term  alterative  is  by  no  means  a  mere  apology  for  ignorance ; 
it  involves  an  important  therapeutical  principle,  viz.,  the  sup- 
planting or  displacing  of  a  morbid  impression,  condition,  or  pro- 
cess in  the  body,  by  the  safer  impression  and  counteraction  of  a 
medicinal  agent.     The  influence  of  the  latter,   physiologically 

1  Gaz.  Medicale  de  Paris,  No.  49,  1872. 
^Gaz.  Hebdomadaire,  No.  8,  1873. 
Loltmann  and  Roteuhofer,  of  Breslau,  have  used  it  with  advantage  iii  cholera  in- 
fantum.    Lyon  Med.,  Feb.  20,  I881. 

15 


170  GENERAL    THERAPEUTICS. 

speaking,  ma}'^  be,  per  se,  abnormal ;  yet,  having  a  sanative  pur- 
pose, it  is  therapeutic. 

This  principle  may  be  sufficiently  illustrated  by  allusion  to  two 
or  three  examples.  In  the  peculiar  and  often  violent  inflamma- 
tion of  the  throat  in  scarlatina,  the  free  application  of  a  strong 
solution  of  nitrate  of  silver  to  the  part  will  almost  invariably  arrest 
(if  used  early)  the  morbid  local  process;  converting  it,  at  all 
events,  from  a  specific  and  dangerous  into  a  simple  and  mild  phlo- 
gosis. 

So  may  the  early  and  powerful  impression  of  the  solid  nitrate 
of  silver,  or  other  caustic,  upon  the  surface  of  the  penis  affected 
with  chancre,  supplant  the  venereal  process,  and  leave  in  its  place 
a  benignant  ulcer. 

When  erysipelatous  inflammation  is  spreading  like  a  conflagra- 
tion from  part  to  part,  a  blister,  or  tincture  of  iodine,  etc.,  will 
sometimes  succeed  in  forming  a  cordon  sanitaire,  by  inducing  its 
own  milder  irritation  in  advance  of  the  disease. 

The  most  essential  part  of  the  treatment  of  chronic  diseases  of 
the  skin,  is  either  alterative  or  antidotal.  Parasitic  affbctions,  as 
scabies,  favus,  mentagra,  etc.,  require  the  destruction  of  the 
epizoon  or  epiphyte  by  an  antidote.  Othei's,  as  eczema,  lichen, 
impetigo,  lepra,  etc.,  when  at  all  obstinate,  are  all  generally 
treated  in  the  same  manner  essentially,  to  whichever  class  the 
disease  may  belong.  Why  ?  Because  the  principle  is  the  same 
in  all — the  alterative  principle.  The  abnormal,  perverted  nutri- 
tion of  the  cutaneous  tissue,  whether  it  be  deeply  or  superficially 
affected,  is  (apart  from  antiphlogistic  or  sedative  treatment,  called 
for  in  certain  cases)  to  be  subverted,  by  a  decisive  change  in  all  its 
conditions ;  and,  speaking  boldly,  it  is  little  matter  what  change, 
so  it  be  considerable.  Any  means  which  will  hurry  the  removal 
of  the  old  diseased  skin,  and  favor  the  immediate  construction 
of  a  new  layer,  will  be  curative,  whether  it  be  only  soap,  water 
and  frictions,  mercurial  ointment,  chrysophanic  acid,  vesication, 
or  the  actual  cautery.'  And  the  same  principle  explains  and  jus- 
tifies the  internal  use  of  arsenic  and  mercury  in  the  management 
of  so  many  very  diverse  forms  of  cutaneous  disease — the  indica- 
tions for  alterative  medication  being  the  same  in  all. 

The  administration,  for  long  periods,  of  minute  doses  of  pow- 
erful alterative  medicines,  in  the  treatment  of  chronic  affections 
which  resist  other  management,  is  less  common  now  than  formerly, 
on  account  of  the  explosion  of  some  old  hypotheses  connected 
with  it.  It  is  very  possible  that  in  this,  as  in  some  other  medical 
reforms,  we  may  have  gone  too  far. 

Agents  which  tend  with  any  degree  of  constancy  to  increase  the 
rate  of  metamorphosis  of  tissue  in  the  body,  are  few.  Mercury 
appears  to  have  this  effect ;  and  its  alterative  power  may  to  a  con- 
siderable extent  be  due  to  this.  It  is  well  known  that  most  of 
the  diuretics  given  for  the  removal  of  dropsical  accumulations  (a 
treatment  often  carried  to  an  irrational  excess),  increase  only  the 

1  Dr.  Hughes  Bennett,  in  the  treatment  of  cutaneous  diseases,  relied  mainly  (London 
Practitioner,  Vol.  I.)  on  the  beneficial  influences  of  waiei'  and  oil;  in  affections  with 
moist  secretions,  water ;  in  those  which  are  dry,  scurfy,  or  scaly,  oil.  Of  course,  how- 
ever. Prof.  Bennett  assigned  some  value  to  other  applications,  as  adjuvants. 


ET.ECTRICITY.  171 

fluid  secretion  of  the  kidneys,  affecting  little  or  not  at  all  their 
solid  excreta.  But  there  is  good  reason  to  believe  that  potassa 
and  soda,  and  some  of  their  compounds,  as  well  as  iodine  and 
mercury,  do  hasten  the  disintegration  of  tissue.  Iodide  of  potas- 
sium has  been  shown  by  Melsens  to  be  in  this  way  ellminatire  of 
lead,  laid  up  in  some  organ  (probably  the  liverj,  removing  it  in 
the  shape  of  iodide  of  lead. 

If  any  possible  measures,  beyond  attention  to  hygiene  and 
repose  can  benefit  cases  of  oi-ganic  degeneration,  we  may  hope  for 
advantage  from  the  combination  of  tonics  or  analeptics  with  alter- 
atives. Dr.  Chambers  (on  Dlyestion  and  its  Derangements)  remarks 
thus :  — 

"In  Bright's  disease,  I  know  of  no  treatment  so  advantageous 
as  that  which  unites  alteratives  (that  is,  hquefacients  of  tissue) 
with  those  restorers  of  blood  par  excdlence,  iron  and  animal  food. " 

Iodide  of  iron  or  iodide  of  potassium  at  the  same  time  with  cod- 
Hver  oil,  may  afford  an  example  of  this  sort  of  medication  in  its 
simplest  form.  Its  object  is  to  favor  the  rapid  removal  of  old 
tissue,  and  the  formation  of  good  new  structure  in  its  place. 

AVhatever  produces  a  powerful  impression,  not  immediately 
destructive  upon  the  system,  may  act  alteratively,  and  some- 
times beneticially,  in  chronic  disease.  Change  of  air,  scene  and 
circumstance  often- exemplifies  this. 

Electricity,  perseveringly  used  as  an  alterative,  in  certain 
cases  of  paralysis  and  other  neuroses,  does  more  good  than  any- 
thing else.  The  ancient  Eomans  used  the  shock  produced  by 
the  torpedo  (electrical  fish)  for  the  cure  of  paralysis  and  gout ; 
and  the  natives  of  Western  Africa  apply  the  sihiriis  in  a  similar 
way,  in  baths,  for  the  treatment  of  sick  children.  Pivati,  of 
Venice,  1740,  and  after  him  De  Haen,  Winkler,  Manduyt,  and 
NoUet,  employed  statical  electricity  as  a  remedy.  G-alvani  (1790) 
and  Volta  introduced  new  means,  which  have  since  been  exten- 
sively used.     Faraday  discovered  the  induced  currents  in  1831. 

At  present,  while  it  is  clear  that  electricity  must  be  capable 
of  powerfully  influencing  the  human  system,  om*  knowledge  of 
its  uses  is  far  from  complete.  Rash  experimentation  with  it  may 
do  harm ;  but  all  its  appliances  may  be  so  graduated  as  to  admit 
of  the  mildest  and  most  cautious  tentative  practice. 

Three  agencies  are  included  under  the  term  electricity  :  1. 
Static  or  frictional  electricity,  of  the  machine  of  glass  and  rub- 
ber. 2.  Galvanic  or  Voltaic  ^  electricity,  the  current  of  the  bat- 
tery, of  metals  with  acid  solutions,  etc.  3.  Faradization,  by 
induced  and  interrupted  currents,  electro-magnetic  or  magneto- 
electric. 

Frictional  electricity  is  least  in  use.  It  is  best  employed  by 
placing  the  patient  on  an  insulated  stool  (with  glass  legs  or  feet) 
and  charging  him  from  either  a  plate  or  a  cylinder  machine ; 
then  withdrawing  the  electricity  by  a  pointed  metallic  conductor, 
if  a  mild  and  general  effect  is  wanted,  or  by  a  round  one  of  some 

1  In  strict  justice,  tliis  ought  to  be  called  Voltaic  electricity.  Galvani  was  the  earlier 
discoverer  iu  the  field  of  animal  electrical  phenomena ;  but  Volta  first  discovered  and 
demonstrated  the  origination  of  electrical  currents  from  chemical  action. 


172  GENERAL    THERAPEUTICS. 

size  to  produce  sparks  and  a  locally  stimulant  effect.  Dr.  Arthius, 
of  Paris,  has  written  a  work  (1873)  upon  the  therapeutic  uses  of 
statical  electricity. 

Voltaic  or  galvanic  electricity  is  developed  by  chemical  action. 
A  battery  consists  of  a  series  of  plates  of  two  materials  (copper, 
zinc,  silver,  carbon,  etc.),  in  alternation,  and  a  liquid  in  contact 
with  both  which  acts  more  upon  one  than  on  the  other.  Daniell's 
and  Smee's  batteries  are  especially  recommended.  Althaus  pre- 
fers a  modification  of  Daniell's,  in  which,  with  copper  and  zinc 
plates,  a  solution  of  sulphate  of  copper  is  used  as  the  liquid.  This 
will  run  for  six  months  without  cleaning ;  with  cleaning,  for  a 
much  longer  time.  The  size  of  the  cups  determines  the  quantity 
of  the  current  of  electricity ;  the  number  of  cups,  its  intensity. 
Quantity  is  especially  powerful  for  chemical  action ;  intensity,  for 
overcoming  the  resistance  of  a  slowly  conducting  medium.  The 
direction  of  the  current,  through  the  wire  or  wires  connecting  them 
outside  of  the  liquid,  is,  in  ordinary  batteries,  from  the  copper 
(or  platinum,  silver,  or  carbon)  to  the  zinc  ;  the  former  being  the 
positive  and  the  latter  the  negative  pole.  Dr.  Hammond^  prefers 
the  direct  to  the  induced  current.  His  apparatus  consists  of  a 
series  of  plates  of  perforated  zinc  and  copper  or  copper  gauze, 
soldered  in  pairs,  with  flannel  between  the  elements.  They  are 
moistened  by  pouring  strong  vinegar  upon  the  top,  so  that  it 
runs  through  the  perforations. 

Faradic  or  induced  electrical  currents  are  usually  obtained  in 
either  of  two  modes  :  1.  By  galvanic  electricity  (from  chemical 
change)  acting  upon  iron ;  making  it  magnetic  during  the  closure 
of  the  circuit,  which  is  interrupted  momentarily  by  a  vibrating 
spring.  A  current  is  thus  induced,  in  one  direction  at  the 
moment  of  closing,  and  in  the  opposite  at  the  opening  of  the  con- 
nection. 2.  By  causing  a  magnet  or  its  keeper  of  iron  to  revolve 
so  as  alternately  to  approach  and  recede  from  contact.  A  helix 
or  coil  of  wire,  wound  around  the  magnet,  will  then  have  an 
induced  current  at  the  moment  of  approach  and  at  that  of  sepa- 
ration. This  (magneto-electric)  is  more  convenient  than  any 
other  apparatus ;  but  some  authorities  claim  greater  power  for 
electro-magnetism  in  therapeutics.  It  has  been  shown  also  that 
the  constant  galvanic  current  (as  of  Daniell's,  Grove's,  Bunsen's,  or 
Smee's  batteries)^  has  a  more  extended  or  general  stimulant  or 
alterative  efiect ;  while  the  interrupted  (faradicj  current  is  more 
powerful  locally.  Proof  of  the  difference  between  the  two  may 
be  obtained  by  ajDplying  them  in  succession  to  the  face.  The 
continued  current  jDroduces  a  flash  of  light  by  its  influence  upon 
the  retina.  The  interrupted  causes  the  muscles  to  contract  in 
proportion  to  its  force.  The  action  of  a  voltaic  or  galvanic 
battery  may  be  readily  interrupted,  by  alternately  lifting  and 
replacing  one  rheophore,^  while  the  other  is  retained  in  contact 

1  Quarterly  Journal  of  Psychol.  Medicine,  etc.,  July,  1867,  p.  62. 

2  The  Leclanche  cell  is  now  a  favorite  with  many  practitioners. 

3  Bheophore,  "  current  bringer ;"  i.  e.,  the  metallic  disk,  moistened  sponge,  brush  of  fine 
wire,  or  other  arrangement  (provided  with  handle)  used  to  apply  electricity  to  any  part 
at  the  will  of  the  operator.  Bheophores  are  constructed  for  introduction  into  the 
rectum,  bladder,  etc.  For  such  use,  all  but  the  end  of  the  conductor  should  be  insulated 
by  being  surrounded  by  gutta-percha  or  india-rubber. 


ELECTRICITY.  173 

with  the  surface  of  the  body.  Renuik  has  expressed  the  grctitcst 
contidencc  in  the  continuous  current ;  especially  that  which  is 
constiint  in  strength.  lie  uses  from  15  to  30  of  Daniell's  cells 
(mo(lilied),  weii^hini;  S  pounds  each.  He  asserts  that  the  down- 
running  curriiut  acts  niost^  upon  the  sensory  nerves,  and  the  up 
current  upon  those  of  motion ;  and  that  while  interrupted  cur- 
rents take  elfect  almost  alone  upon  the  muscles,  con.stant  cur- 
rents act  upon  the  nerve-centres  themselves.  Hiflelsheim  and 
Onimus  have  extended  Remak's  investigations.  It  has  been 
shown  (E.  AVeber,  Matteucci,  Erb)^  that  a  constant  current  may 
be  made  to  take  effect  upon  the  brain  and  spinal  marrow.  Kiihne 
and  others  have  also  found,  by  the  aid  of  the  microscope,  distinct 
action  of  the  constant  current  upon  organic  cells  and  protoplasm ; 
a  ciiange  of  form  of  the  cell  sometimes  resulting,  which  has  been 
called  cell-ietamis. 

Duchenne,  of  Bologne,  asserts,  as  the  conclusions  derived  from 
his  experience,  the  following  : 

"  In  man,  whatever  may  be  the  direction  of  the  currents,  or 
the  degree  of  vitality  of  the  nerves  they  traverse,  the  same 
results  are  always  produced  when  the  conductors  are  applied  to 
any  part  over  the  course  of  the  nerves, — namely,  muscular  con- 
tractions and  sensations. 

"  Various  changes  in  the  current-direction  produce  no  appre- 
ciable influence  over  the  sensibility,  or  capability  of  voluntary 
muscular  contraction,  in  man." 

On  the  basis,  however,  mainly  of  Dubois  Reymond's  experi- 
ments, other  electricians  insist  that  a  current  towards  the  centres 
of  the  body  stimulates  the  sensory  nerves,  while  it  lessens  the 
■  excitability  of  the  motor  nerves  ;  and  that  a  current /rwn  the  cen- 
tres out  to  the  periphery  stimulates  motor,  and  acts  as  a  sedative 
to  sensory  nerves.  Pereira  says,  "  In  paralysis  of  sensation  only, 
the  current  should  be  direct  or  centrifugal.  In  paralysis  of  mo- 
tion, it  should  be  inverse  or  centripetal.  In  paralysis  of  both 
sensation  and  motion,  the  vibrating  current  (faradization)  is 
peculiarly  appropriate ;  for  by  this  the  sensitive  and  motor 
nerves  are  alternately  excited,  while  the  one  current  promotes 
the  restoration  of  the  excitability,  which  may  have  been  lessened 
by  the  preceding  current." 

Hitzig,  Brenner,  Chauveau,  De  Watteville,  Benedict,  and 
Russell  Reynolds,'^  all  sustain  the  above  quoted  judgment  of 
Duchenne,  as  to  the  absence  of  specific  differences,  practically 
available,  according  to  the  directinn  of  the  current  applied  ;  while 
the  locality  of  the  application  is  of  the  greatest  importance.  It 
does  not  appear  to  be  proved  that  either  poZe,  as  such,  has  pecu- 
liar "anodyne  or  stimulant"  powers,  as  some  have  supposed. 

As  a  general  rule,  it  may  be  said,  that  the  continuous  voltaic 
(galvanic )  current  tends  to  produce  a  tranquillizing  effect  upon 
spasmodic  over-action ;  while  the  interrupted  faradic  current  is 


1  Budge  and  Waller  have  reported  remarkable  observations  upon  the  "centrum  cilio- 
spinale,"  in  relation  to  the  action  of  the  iris.  See  M.  Meyer,  Medical  Electricity,  transL 
by  Hammond,  p.  77. 

2  Cited  by  Dr.  L.  Carter  Gray,  N.  Y.  Med.  Rec,  August,  1879. 

15* 


174  GENERAL    THERAPEUTICS. 

especially  stimulant  to  enfeebled  and  atrophied  muscles,  and  to  a 
sluggish  circulation. 

For  the  use  of  frictiorial  (machine)  electricity,  whose  effects 
are  most  like  those  of  the  faradic  current.  Dr.  Bartholow  rec- 
ommends the  Toepler-Holtz  machine  as  most  efficient  and 
reliable. 

Dr.  Moritz  Mayer  ^  lays  down  the  following  as  the  best  estab- 
lished facts.  1.  Electricity  is  a  stimulus.  2.  It  increases  the  sup- 
ply of  blood  to  the  irritated  part.  3.  It  augments  also  its 
temperature,  and  tends  to  increase  its  volume.  4.  It  enhances 
the  contractile  energy  of  the  vascular  walls.  5.  It  counteracts 
the  secondary  changes  occurring  in  inactive  nerves  and  muscles. 
6.  It  is  capable  of  aiding  in  the  restoration  to  nerves  and  mus- 
cles of  their  lost  functional  power.  7.  It  is  capable  of  develop- 
ing a  supplementary  function  in  muscular  fibres  not  yet  par- 
alyzed. 

Dr.  G.  M.  Beard  recommends  the  use,  in  many  chronic  affec- 
tions, of  "  central  galvanization  ; "  the  negative  pole  being  placed 
at  the  pit  of  the  stomach,  and  the  positive  pole  applied  success- 
ively to  the  head,  over  the  sympathetic  and  pneumogastric  in 
the  neck,  and  to  the  spine  ;  the  whole  of  the  central  nervous 
system  being  thus  brought  under  the  influence  of  the  current. 

The  precautions  needful  in  employing  electricity  as  a  remedial 
application  are — 

1.  Always  to  begin  with  it  very  gently,  watching  carefully  its 
effects  ;  contiiming  it  therefore  at  first  but  for  a  few  minutes  at 
once.  The  hand  o/  the  operator  is  the  gentlest  and  best  electrode 
for  sensitive  or  irritable  parts.  To  use  it,  of  course  the  electric- 
ity must  pass  through  the  operator's  body.  This  mode,  however, 
is  not  commonly  resorted  to. 

2.  To  be  especially  careful  in  its  use  at  or  near  the  great  nerve 
centres,  as  the  brain  and  spinal  marrow. 

3.  Avoid  using  it,  even  locally,  during  the  existence  of  an 
inflammation  or  acute  irritation  of  the  spinal  marrow  or  brain. 

The  idea  which  Dr.  Radclifte  has  especially  advocated,  of  using 
galvanism,  e.g.,  in  neuralgia,  or  convulsions,  with  such  force  as 
to  partially  or  temporarily  paralyze  a  disordered  nerve-centre,  is, 
I  am  sure,  unsound  in  theory  and  very  unsafe  in  practice.  I 
would  not  think  of  resorting  to  such  a  measure  in  any  conceivable 
case. 

The  affections  in  which  electricity,  in  various  modes  of  appli- 
cation, has  been  found  most  positively  and  frequently  serviceable 
are  paralysis  (especially  hysterical,  reflex,'^  infantile)  and  lead  palsy, 
aphonia  and  diphtheritic  paralysis  of  the  throat ;  neuralgia.,  chronic 
rheumatism,  exophthalmic  goitre,  angina  pectoris,  amenorrhoea,  sup- 
pression of  lactation,  obstruction  of  the  bowels,  lead  colic,  cancerous 
or  other  tumors,  eczema,  herpes,  prurigo.^  In  surgery,  galvano- 
puncture  is  resorted  to  for  aneurisms,  etc.  In  treatment  of 
asphyxia,  narcotic  coma,  etc.,  its  powerful  stimulation  is  some- 

1  Medical  Electricity,  p.  372. 

2  See  Mitchell,  Morehouse,  and  Keen  upon  Wounds  of  Nerves,  etc. 

*  In  one  case  I  have  known  it  to  appear  to  retard  the  progress  of  piilmonai-y  pMiisis 
for  a  considerable  period. 


HYDROPATHY.  175 

times  an  irnportant  moans  of  saving  life.  Applied  to  nncuriam 
of  the  thoracic  aortn^  tlu;  ol)joct  is  to  produce  coiij^ailation  of  blood 
in  the  tumor.  The  best  mode  of  operating  is  as  follows :  two 
sharp  platinum  needles  coated  with  gutta-percha  an;  successively 
plunged  into  the  tumor,  gver  which  the  skin  has  first  been 
benumbed  with  ice  or  spray  of  ether  or  rhigolene.  The  needles 
having  been  connected  with  a  voltaic  battery,  tlie  current  is 
gradually  increased  to  its  full  strength  and  continued  so  for 
several  minutes,  after  which  the  needles  are  withdrawn. 

Crussell,  Spencer  Wells,  and  Hannnond  rejjort  gi'cat  success 
in  causing  the  healing  of  indolent  ulcers  and  bed-sores  by  mild, 
constant  currents.     Dr.  Hammond's  method  is  the  following : 

"A  thin  silver  plate,  no  thicker  than  a  sheet  of  paper,  is  cut 
to  the  exact  size  and  shape  of  the  bed-sore;  a  zinc  plate  of  about 
the  same  size  is  connected  with  the  silver  plate  by  a  line  silver  or 
copper  w^ire  six  or  eight  inches  in  length.  The  silver  plate  is 
then  placed  in  immediate  contact  with  the  bed-sore,  and  the  zinc 
plate  on  some  part  of  the  skin  above,  a  piece  of  chamois-skin 
soaked  in  vinegar  intervening.  This  must  be  kept  moist,  or 
there  is  little  or  no  action  of  the  battery.  Within  a  few  hours 
the  effect  is  perceptible,  and  .in  a  day  or  two  the  cure  is  complete 
in  the  great  majority  of  cases.  In  a  few  instances  a  longer  time 
is  required." 

The  use  of  electricity  in  diagnosis  will  be  alluded  to  in  another 
part  of  this  book. 

Hydropatliy  (hydrotherapy^  is  an  example  of  a  most  valuable 
agent  misapplied  by  exclusivism,  which  is  always  quackery, — 
that  is,  it  is  quackery  to  deny  the  virtues  of  other  remedies,  no 
matter  how  long  or  well  established,  in  extolling  those  of  one 
made  the  sole  prmacea  of  practice.  Bathing  (local  and  general), 
douches,  and  even  packing  in  the  wet  sheet,  are,  if  used  with 
judgment,  potent  alterative  and  often  sanative  means.  Almost 
hopeless  chronic  cases  of  nervous  disorders,  dyspepsia,  chronic 
rheumatism,  etc.,  may  sometimes  have  their  languid  vitality 
aroused  by  the  revolutionizing  action  of  such  processes.  The 
danger  is  of  unprofessional  and  ill-judging  abuse  of  an  agency 
of  such  power. 

Hot-air  baths  have  of  late  years  attracted  attention. 

M.  Fillet  (1764),  Fordyce,  Blagden  (1775),  and  others,  proved, 
as  Chabert  the  "Fire  King"  also  illustrated,  that  a  dry-air  heat 
above  that  of  boiling  water  can  be  borne  by  the  human  body  with 
safety.  Within  a  few  years  the  use  of  the  hot-air  bath,  similar 
to  that  of  the  calidarium  of  the  ancient  Romans,  has  been  intro- 
duced for  remedial  purposes.  It  is  misnamed  the  "Turkish 
Bath,"  as  the  latter  includes  a  vapor  bath  at  a  temperature 
below  100°. 

Erasmus  Wilson,  the  dermatologist,  Urquhart,  and  others, 
have,  upon  personal  experience,  lauded  the  virtues  of  the  hot-air 
bath.  The  requisites  are  a  heated  metallic  surface  (a  common 
stove  will  do)  to  warm  the  air  of  the  apartment,  and  an  adjoin- 
ing convenient  water  bath,  with  warm  or  cool  water,  to  plunge 
into  after  or  alternately  with  the  air  bath. 


176  GENERAL    THERAPEUTICS. 

TJrquhart  thus  speaks  of  its  use  in  health:  "When  I  come 
back  to  it  after  its  absence  and  the  use  of  other  baths,  even  the 
best,  it  is  like  getting  ^n  the  back  of  a  thorough-bred  after  hav- 
ing to  ride  a  cart-horse.  It  is  of  service  at  every  moment,  and 
at  all  temperatures.  You  come  in  from  a  journey,  say  before 
dinner ;  you  go  in  not  heated,  when  it  may  stand  at  120° ;  you 
dress  at  that  charming  temperature,  with  streams  of  hot  or  cold 
water,  or  the  tank  to  revel  in.  So,  also,  you  may  dress  in  the 
morning.  My  regular  practice,  when  not  requiring  it  for  health's 
sake,  is  to  go  in  on  getting  up  and  on  going  to  bed,  dressing  and 
undressing  there  ;  five  to  ten  minutes  suffice  to  bring  on  the  flow 
of  perspiration.  After  that  a  plunge  in  the  cold  water,  and  you 
come  out  fresh,  glowing  with  a  sense  of  cleanliness,  health,  and 
strength,  which  no  other  operation  can  convey  to  the  body. 
You  are  then  indifferent  to  the  heat  of  summer  and  the  cold 
of  winter." 

Copious  perspiration  and  the  thorough  removal  of  the  effete 
cuticle,  as  well  as'of  all  foreign  impurity,  from  the  surface  of  the 
body  are  the  obvious  and  direct  effects  of  the  hot-air  bath. 
Depuration  and  functional  balance  of  the  excretory  processes  are 
thus  promoted,  while  the  stimulant  influence  of  heat,  so  often 
useful  in  cases  of  depressed  vitality,  is  obtained.  Renewal  of 
the  nutrition  of  the  skin  must  also  be  more  rapid  under  such  a 
process.  The  temperature  is  made  to  vary  between  120°  and 
200° ;  130°  to  140°  is  a  good  standard. 

The  diseases  in  which  the  hot-air  bath  has  been  tried  with 
favorable  results,  in  cure  or  palliation,  are,  especially,  acute  and 
chronic  rheumatism,  lumbago,  sciatica,  neuralgia,  gout,  dropsy, 
catarrh,  influenza,  throat  affections,  diarrhcea,  dysentery,  slug- 
gishness of  circulation,  disorders  of  the  liver,  scrofula,  incipient 
phthisis,  Bright's  disease,  ague,  obstinate  skin  diseases,  chorea, 
mania ;  also,  it  is  said,  even  cholera  and  hydrophobia. 

Hot  sand-baths  have  been  used  in  London  by  Dr.  Conradi^  and 
others  to  promote  perspiration  and  relieve  congestion  of  the 
internal  organs. 

Mustard  Bathing, — Dr.  S.  Kewington,  of  England,  ascertained 
by  experience  in  his  own  person  that  the  extensive  and  continued 
application  of  mustard  to  the  body  is  a  powerful  tranquilizer  of 
nervous  excitement  and  means  of  restoration  of  the  balance  of 
a  disturbed  circulation.  Use  of  the  same  remedy  with  a  number 
of  patients  has  confirmed  its  value.  One  mode  of  its  application 
is  as  follows :  Two  handfuls  of  powdered  mustard  are  tied  in  a 
cloth  and  placed  in  hot  water,  then  squeezed  in  the  hand  until 
the  strength  of  the  mustard  has  been  extracted.  A  thick  towel 
long  enough  to  reach  around  the  loins  is  then  wrung  out  of  this 
infusion,  wrapped  round  the  body,  and  covered  with  a  large  piece 
of  oiled  silk  or  gum-elastic  cloth.  Another  plan  is  that  of  the 
mustard  bath, — that  is,  an  ordinary  warm  bath  into  which  have 
been  thrown  five  or  six  handfuls  of  mustard. 

In  maniacal  excitement^  particularly,  these  applications  have 
been  found  usefully  sedative.  SleexAessness^  from  any  cause,  may 
be  so  treated,  as  well  as  hysteria,  etc.     It  may  be  expected  that 

1  Med.  Times  and  Gaz.,  October  19,  1872,  p.  150. 


MASSAGE.  177 

such  a  process  will  be  useful  also  in  promotinjif  reaction  in  cases 
of  internal  congestion;  porliapsf  in  the  chill  of  pernicious  fever, 
in  "spotted  fever,"  and  in  the  incipient  collapse  of  cholera. 

Movement-cure  {kinesipathy)  is  the  name  for  a  kind  of  practice 
(Taylor)  founded  upon  the-  teachinf^^s  of  Ling,  of  Sweden,  con- 
sisting of  2J«.s.su'e  exercise  of  the  muscles,  for  the  purpose  of  im- 
proving the  circulation,  innervation,  and  reparative  nutrition  of 
diseased  and  enfeebled  organs. 

Although  an  elaborate  system  of  particular  movements  upon 
a  gM«.s?-physiological  rationale  has  been  devised  and  adapted  to 
each  kind  of  chronic  local  or  general  disorder,  careful  examina- 
tion of  the  treatise  of  an  authority  upon  the  subject  convinces 
me  that  this  is  all  surplusage.  What  remains  to  be  true  is  that 
where  active  exercise  is  not  practicable,  systematic  frictions  and 
passive  movements  of  all  parts  of  the  body  are  very  useful  in  its 
stead.  What  is  added  to  this  by  the  specialist  is,  faith  on  the  part 
of  the  patient  and  perseverance  in  the  attendant,  —  two  things 
which,  without  extraordinary  processes,  explain  much  and  ac- 
count for  many  cures. 

Massage  is  the  term  applied  to  systematic  rubbing  and  knead- 
ing the  muscles  and  other  accessible  parts  of  the  body.  It  is 
an  ancient  practice,  common  even  among  some  savage  nations. 
The  lomi-lomi  of  the  Sandwich  Islands^  is  of  this  character. 
It  is  familiar  to  the  Brahmins  in  India,  and  is  traced  as  far  back 
as  to  the  Egyptian  priests,  before  Hippocrates.  It  is  now  used 
especially  in  cases  of  general  and  nervous  debility,  in  which  mus- 
cular exercise  is  not  to  a  sufficient  extent  obtainable. 

Dr.  S.  AVeir  Mitchell"  thus  describes  this  procedure : 

"An  hour  is  chosen  midway  betAveen  two  meals,  and  the 
patient  lying  in  bed,  the  manipulator  starts  at  the  feet  and  gently 
but  firmly  pinches  up  the  skin,  rolling  it  lightly  between  his 
fingers  and  going  carefully  over  the  whole  foot ;  then  the  toes 
are  bent  and  moved  about;  in  every  direction,  and  next,  with  the 
thumbs  and  fingers,  the  little  muscles  of  the  foot  are  kneaded 
and  pinched  more  largely,  and  the  inter-osseous  groups  worked 
at  with  the  finger-tips  between  the  bones.  At  last  the  ankles 
are  dealt  with  in  like  fashion,  all  the  crevices  between  the  artic- 
ulating bones  being  sought  out  and  kneaded,  while  the  joint  is 
put  in  every  possible  position.  The  leg  is  next  treated,  first  by 
surface-pinching  and  then  by  deeper  grasping  of  the  areolar 
tissue,  and  last  by  industrious  and  deeper  pinching  of  the  large 
muscular  masses,  which  for  this  purpose  are  put  in  a  position  of 
the  utmost  relaxation.  The  grasp  of  the  muscles  is  momentary, 
and  for  the  large  muscles  of  the  calf  and  thigh  both  hands  act, 
the  one  contracting  as  the  other  loosens  the  grip.  In  treating 
the  firm  muscles  in  front  of  the  leg,  the  fingers  are  made  to  roll 
the  muscles  under  the  cushions  of  the  finger-tips.  At  brief 
intervals  the  manipulator  seizes  the  limb  in  both  hands,  and 
lightly  runs  the  grasp  upwards,  so  as  to  favor  the  flow  of  venous 
blood-currents,  and  then  returns  to  the  kneading  of  the  muscles. 

1  K^rdhoff:  Northern  California,  Oregon,  and  the  Sandwich  Islands,  1874. 

2  Fat  and  lilouU,  and  How  to  Make  Them,  p.  52. 

M 


178  GENERAL    THERAPEUTICS. 

The  same  process  is  carried  on  in  every  part  of  the  body,  and 
especial  care  is  given  to  the  muscles  of  the  loin  and  spine,  while 
usually  the  face  is  not  touched." 

At  first  this  is  continued  for  but  lialf  an  hour  at  once  ;  gradu- 
ally it  is  increased  to  an  hour  daily  or  every  other  day.  After 
each  rubbing  the  patient  should  have  at  least  an  hour's  absolute 
repose. 

Dr.  Mitchell  advises  the  use  of  cocoa  oil  or  vaseline  to  lubricate 
the  parts  rubbed.  My  belief  is  that  more  stress  might  be  placed 
upon  this  inunction,  as  itself  an  important  portion  of  the  treat- 
ment. The  ancients  resorted  largely  to  anointing  for  sanitary 
and  remedial  (as  well  as  religious)  purposes.  Their  wisdom  in 
this  has  been  too  much  neglected.  Cod-liver  oil  inunction  in 
scrofulosis  of  children,  and  in  some  obstinate  forms  of  skin  dis- 
ease, has  decided  therapeutic  value.  Although  but  little  oil  may 
be  absorbed  through  the  skin,  it  has  been  proved  that  the  ten- 
dency to  emaciation  may  be  arrested  or  abated  by  inunction. 

One  of  the  drawbacks  in  the  use  of  massage  is  that  so  much 
depends  on  the  judgment,  dexterity,  and  tact  of  the  rubber 
(masseur  or  masseuse).  Dr.  Mitchell's  advice  to  disregard  such 
symptoms  as  increased  nervousness  and  even  loss  of  sleep,  fol- 
lowing the  daily  massage,  is,  as  I  know  from  observation,  not 
safe.  Average  professional  rubbers  sometimes  do  harm  instead 
of  good.  The  constant  oversight  of  the  medical  adviser  is  neces- 
sary; and  there  are  some  cases  of  neurasthenia  in  which  this 
method  does  not  prove  advantageous.  It  is  likely  to  do  good  par- 
ticularly in  paralysis^  chronic  rheumatism^  and  sprains  of  the  joints. 
Electro-massage  is  sometimes  practised,  by  the  use  of  a  metallic 
brush  of  fine  wire,  connected  with  a  battery. 

Under  any  treatment,  however,  we  must  not  encourage  sanguine 
hopes  in  instances  of  organic  degeneration,  the  origm  of  which 
is  so  generally  to  be  found  in  a  failure  of  systemic  vital  power. 
The  physician  will  do  much  for  his  patient  if  he  can  persuade 
and  instruct  him  to  adapt  his  living  to  the  actual  condition  of 
his  physical  resources,  so  that,  whether  his  malady  be  Bright's 
disease  of  the  kidney,  diabetes  mellitus,  cirrhosis  of  the  liver, 
locomotor  ataxy,  or  fatty  or  other  organic  disease  of  the  heart, 
he  may  economize  both  the  material  and  the  force  of  his  system 
by  such  a  regimen  of  diet,  exercise,  and  excitement  as  his  state 
requires. 

With  such  management,  it  often  happens  that  valetudinarians 
live  longer  than  those  who,  with  sound  constitutions,  are  less 
watchful  against  causes  of  disease,  and  less  prompt  in  taking  warn- 
ing from  the  slightest  symptoms  or  approaches  of  ill  health. 

Nor  need  we  look  upon  the  failure  of  medicine  to  arrest  the 
process  of  organic  degeneration  as  a  subject  of  very  humiliating 
discouragement.  As  death  is  the. natural  result  of  life,  in  the 
human  organism  as  in  every  other  material  form,  this  partial 
death  occurs,  also,  under  physiological  laws ;  and,  if  it  be  rela- 
tively premature  in  certain  instances,  we  may  believe  that  this, 
too,  may  be  traced  to  a  near  or  remote  causation  in  perfect 
harmony  with  the  highest  interests,  moral  and  physical,  of 
man.  * 


INHALATION    AND    ATOMIZATION.  179 

1NIIAI.ATION   AND   ATOMIZATION. 

Although  the  ancient  Egyptians  had  some  knowledge  of  the 
effects  of" drugs  whose  vapors  were  inhaled,  and  Hippocrates, 
Cralen,  and  other  Roman  physicians,  as  well  as,  later,  the  Ara- 
hians,  so  employed  them,  they  were  afterwards  long  lost  sight  of. 
Bennet,  of  London,  in  the  seventeenth  century,  seems  to  liave 
heen  the  first  in  modern  times  to  use  inhalations  systematically. 
The  earliest  proper  instrumental  inhaler  was  probably  that  of 
Dr.  John  Miulge,  an  English  physician,  invented  and  applied  in 
171)9.  St.  John  Long,  the  charlatan,  used  lai'ge  inhalers,  from 
which  a  number  could  breathe  at  once,  Bocrhaave  and  Von 
Swieten,  in  the  early  part,  and  Beddoes  at  the  end,  of  the  eigh- 
teenth century,  employed  medicated  inhalations.  Scudamore, 
in  18:50,  issued  a  work  upon  the  subject  which  had  a  wide  circu- 
lation. 

Since  that  time,  an  immense  amount  of  experimentation  has 
been  made,  to  ascertain  what  local  effects  upon  the  lungs  and 
air-tubes,  and  what  action  upon  the  system  at  large,  might  be 
ol)tained  by  vapors  brought  in  contact  with  the  highly  absorbent 
respiratory  membrane.  Most  important  of  all,  of  course,  was 
the  discovery  of  gaseous  anoesthcsia  by  Sir  Humphrey  Davy,  and 
the  subsequent  practical  application  of  it  by  Wells  and  Morton. 
Ether,  chloroform,  nitrous  oxide,  and  bichloride  of  methylene 
now  take  their  places  not  only  as  alleviators  of  pain  during  oper- 
ations and  in  parturition,  but,  also,  as  occasionally  valuable  aids 
to  the  physician  in  medical  cases.  Extreme  neuralgic  pain  is 
sometimes  relieved  by  the  inhalation  of  ether  or  one  of  the  other 
anaesthetics.  Convulsions  are  not  unfrequently  so  treated  ;  and, 
in  those  at  least  of  a  hysterical  or  merely  irritative  character, 
with  good  success.  Angina  pectoris  is  often  relieved  by  breath- 
ing a  few  drops  of  nitrite  of  amyl. 

For  medical  as  well  as  surgical  use,  chloroform  is  the  most 
prompt,  quiet,  and  effectual  anesthetic.  In  cases  of  disease,  it 
does  not  need  to  be  so  given  as  to  produce  the  total  relaxation  of 
profound  anaesthesia.  Can  its  use  be  justified,  in  view  of  the  fact 
that  a  considerable  number  of  deaths  have  been  traced  to  it  ? 

Without  space  to  discuss  this  point,  I  may  say  that  observation 
of  the  use  of  chloroform  in  a  method  employed  by  some  of  the  sur- 
geons of  the  United  States  army  during  the  civil  Avar,  has  modi- 
fied my  previous  apprehension  of  it.  The  great  necessity  is,  as 
Dr.  Sansom'  has  shown  very  fully,  the  dilution  of  the  chloroform 
with  abundance  of  air,  and  its  gradual  introduction.  Most  meth- 
ods exclude  air  too  much.  That  which  I  have  alluded  to  above 
is,  letting  the  chloroform  fall,  dnq)  hy  drop,  upon  a  handkerchief 
spread  singly  over  the  face  of  the  patient.  An  instrument  is 
used  for  dropping,  which  will  allow  only  one  drop  to  pass  at  once. 
I  believe  that,  with  this  or  any  other  mode  of  abundant  dilution 
and  slow  inhalation  of  it,  watching  momentarily  its  efiects,  chlo-- 
roform  is  safe,  in  an  immense  majority  of  cases.  Anaesthesia  from 
chloroform  cannot  with  safety  be  produced  in  less  than  five  or  six 
minutes. 

1  On  Chloroform ;  its  Action  and  Administration. 


180  GENERAL    THERAPEUTICS. 

Ether  excites  some  persons  too  much  to  be  generally  relied 
upon  in  medical  case^.  Two  or  three  parts  of  ether  with  one  of 
chloroform  make  a  mixture  often  used  with  advantage.  Dr. 
Sansom  prefers  one  part  of  chloroform  to  one  or  two  of  absolute 
alcohol.  Dr.  B.  W.  Richardson  combines  ether  with  bichloride 
of  methylene.  Nitrous  oxide,  although  experimented  upon  by 
Davy  and  used  by  "Wells  before  ether,  has  only  of  late  come  to 
be  highly  appreciated  for  practical  use.  Its  applications  by  inha- 
lation in  disease  remain  to  be  tried  and  studied.  The  same  is 
true  of  bromide  of  ethyl.  Compressed  air  (Waldenburg)  and 
oxygen  gas  are  now  considerably  employed  for  inhalation  in  con- 
sumption. Some  practitioners  believe  the  chief  benefit  to  result 
from  mechanical  expansion  of  the  air-cells  of  the  lung. 

Apart  from  the  "  anaesthetics, "  it  cannot  be  said  that  great 
success  has  ever  been  obtained  in  the  cure  of  diseases  by  inhala- 
tion. Palliation  of  pulmonary  and  bronchial  or  laryngeal  irri- 
tatioH,  or  diminution  of  excessive  expectoration,  as  by  simple 
vapor  of  water,  tar-vapor,  or  that  of  infusion  of  hops,  opium, 
etc.,  has  been  often  realized.  "With  other  aims  and  agents,  dis- 
appointment has  generally  predominated. 

For  ordinary  inhalation,  very  simple  apparatus  will  suffice. 
For  instance,  a  wide-mouthed  jar  or  bottle,  with  a  cork  in  it ; 
the  cork  pierced  by  two  glass  tubes,  one  straight,  and  reaching 
to  near  the  bottom  of  the  bottle  ;  the  other  short,  and  bent  out- 
side of  the  cork.  The  bottle  is  to  be  not  quite  filled  with  the 
liquid  (more  or  less  heated  according  to  its  volatility) ;  the  bent 
tube  not  reaching  its  surface,  the  other  conveying  air  into  it  from 
beyond  the  cork.  Even  this  is  not  necessary,  at  least  in  the  case 
of  liquids  used  with  water.  We  may  employ  these  by  pouring 
boiling  water  into  a  convenient  vessel  of  any  kind,  the  medica- 
ment being  added  to  it,  and  then  covering  the  vessel  with  a 
towel,  holding  the  mouth  and  nostrils  under  the  edge  of  the  lat- 
ter. Hops  in  infusion,  stramonium  leaves,  laudanum,  etc.,  may 
thus  be  used.  Of  laudanum,  e.  g.,  twenty  or  thirty  drops  may  be 
put  into  a  pint  of  water,  for  a  very  worrying  cough.  Smoking  is 
a  primitive  method  of  inhalation.  Tobacco,  so  employed,  some- 
times relieves  in  asthma ;  but  cigars  of  stramonium  leaves,  or  of 
paper  saturated  with  nitrate  of  potassium,  are  more  effectual  in 
the  paroxysms  of  the  same  disorder.  Continuous  inhalation  is 
sometimes  desirable.  For  this,  Dr.  W.  Eoberts's  small  and 
light  metallic  box  may  be  used.  It  is  perforated  in  front  and 
behind,  and  filled  loosely  with  tow,  into  which  the  desired  liquid 
is  poured  for  inhalation.  It  may  then  be  fixed  by  elastic  bands 
over  the  ears,  and  worn  for  some  time  without  inconvenience. 
Curschmann  has  devised  a  similar  respirator  made  of  vulcanite, 
with  a  rim  of  soft  India-rubber.  A  simple  glass  or  metal  tube 
will  answer  for  a  shorter  period.  Dr.  Pepper  employs  a  tube 
enlarged  near  its  lower  end,  in  which  pumice-stone  is  placed  to 
receive  the  material  for  inhalation. 

Dr.  Andrew  H.  Smith's  insufflator  is  sometimes  convenient  to 
introduce  powders  into  the  larynx.  It  consists  of  a  small  wide- 
mouthed  bottle,  through  whose  cork  are  passed  two  tubes,  each 
bent  at  right  angles.     To  one  is  attached  a  rubber  hand-ball ; 


INHALATION    AND    ATOMIZATION.  181 

the  other  is  placed  near  the  orifice  of  the  glottis.  When  the 
medicated  powder  has  been  put  into  the  bottle,  the  compression 
of  the  hand-ball  will  blow  the  powder  out  through  the  other  tube 
into  the  throat. 

Extremely  minute  division  or  atomizahon  of  liquids,  introduced 
into  the  air-passages,  has  been  latterly  often  substituted  for  inhala- 
tion. It  was  first  devised  by  Sales-Girons.  Under  the  natural 
fascination  of  novelty,  and  the  imposing  appearance  presented 
by  instrumental  appliances,  it  is  quite  probable  that  a  degree 
oir  enthusiasm  has  existed  about  it,  more  than  will  be  permanent. 
Still  it  is  an  important  addition  to  our  means  of  treatment  of 
affections  of  the  throat,  and,  perhaps,  of  some  of  those  of  the 
lungs.  Referring  the  reader  to  special  works'  upon  it  for  details, 
I  must  give  only  the  briefest  account  of  atomization  or  nebu- 
lization. 

The  essential  idea  of  it  is,  the  forcing  of  a  fine  jet  of  liquid 
against  a  solid  body  or  a  strong  current  of  air,  so  as  to  convert 
it  at  once  into  diffused  spray.  Bergson,  for  instance,  employed 
the  tubes  used  for  odoratnrs^  that  is,  to  spread  perfumed  liquids 
in  the  air.  Two  glass  tubes  with  minute  orifices  are  fixed  at 
right  angles  to  eacli  other,  so  that  the  end  of  the  upright  tube  is 
near  and  opposite  to  the  centre  of  the  orifice  of  the  horizontal 
tube.  The  upright  tube  being  immersed  in  the  liquid  to  be 
nebulized,  air  is  forcibly  blown  through  the  horizontal  one.  The 
current  of  air,  passing  over  the  outlet  of  the  tube  communicating 
with  the  liquid,  rarefies  the  air  in  the  latter,  causing  a  rise  of 
the  liquid  in  the  tube,  and  its  very  minute  subdivision  (atomiza- 
tion, nebulization,  pulverization),  as  it  escapes.  Silver  tubes 
may  be  used  instead  of  glass,  but  they  are  harder  to  keep  clean. 
Glass  ones  may  be  cleaned  with  hydrochloric  acid  solution,  aided 
by  a  bristle  to  remove  obstructions.  The  form  of  the  tubes  may 
be  varied,  so  as  to  allow  of  their  application  to  any  part  of  the 
body. 

Richardson's  spray-producer  (designed  for  local  refrigeration) 
is  constructed  upon  a  similar  principle.  It  consists  of  a  gradu- 
ated bottle,  through  whose  cork  passes  a  double  tube ;  that  is.  a 
tube  within  a  tube.  The  inner  one  reaches  to  near  the  bottom 
of  the  bottle,  below,  and  above  near  to  the  extremity  of  the  outer 
tube.  The  latter  has  entering  it,  above  the  cork,  another  tube 
connected  with  "hand  bellows" — i.  f.,  two  elastic  bags,  the  one 
nearest  the  bottle  (protected  by  silk  network)  acting  as  an  air- 
chamber,  and  the  furthest  one  being  compressed  by  the  hand,  to 
produce  a  jet  of  air  into  the  bottle  and  tube. 

Siegle  contrived  an  apparatus  for  the  application  of  steam-' 
power  to  atomization.  The  tubes  being  arranged  upon  Bergson's 
principle,  a  small  boiler  is  connected  with  the  horizontal  one, 
and  in  the  boiler  steam  is  generated  by  the  heat  of  a  spirit  lamp. 
The  jet  of  steam  from  the  horizontal  tube  nebulizes  the  liquid 
drawn  up  from  the  vertical  tube  immersed  in  a  vessel  containing 
it.    Various  modifications  of  this  have  been  made.^     Though  the 

1  See  Da  Costa  on  Inhalation. 

-  Gemrig,  of  Philada.,  Dr.  W.  Reed,  of  Boston,  and  Codman  and  Shurtleff,  of  Boston, 
furnish  improved  forms  of  apparatus  for  atomization. 

16 


182  GENERAL    THERAPEUTICS. 

Steadiness  of  action  of  the  steam  apparatus  must  be  a  great 
advantage,  for  many  purposes  the  hand-ball  atomizer  is  more 
available. 

For  full  effectiveness  of  any  method  of  inhalation  in  chronic  or 
subacute  cases,  the  patient  must  have  the  instrument  at  his  own 
house,  learn  its  management,  and  use  it  with  regularity  for  a 
sufficient  time.  This  of  course  limits  very  much  the  employment 
of  such  medication. 

The  first  inhalations  should  always  be  short,  and  with  warm 
water  only,  to  inure  the  patient  to  their  use.  The  distance  of 
the  mouth  from  the  tubes  may  vary  from  six  inches  to  two  feet. 
When  prepared  for  it,  one  may  inhale  "medicated  spray"  for 
ten  minutes  at  a  time ;  breathing  deeply  if  we  wish  the  liquid  to 
reach  the  remoter  air-passages.  It  should  never  be  done  after  a 
hearty  meal ;  and  the  patient  should  remain  in-doors  for  a  while 
after  the  operation. 

Proof  has  been  obtained  that  atomized  liquids  inhaled  do,  some- 
times at  least,  pass  down  into  the  trachea ;  constantly,  into  the 
larynx.  It  is  probable,  indeed  almost  certain,  that  a  certain 
portion  may  even  reach  the  lungs.  As  to  their  application,  trial 
has  been  and  is  now  being  made  of  this  process,  especially  in 
croup,  diphtheria,  oedema  of  the  glottis,  catarrh,  chronic  laryn- 
gitis, hooping-cough,  asthma,  pulmonary  hemorrhage,  and 
phthisis. 

False  membrane  has  been  asserted  by  Kiichenmeister,  Biermer, 
Geiger,  and  others,  to  be  dissolved,  or  at  least  removed  from  the 
throat,  by  inhalation  of  hot  lime-water.  Dr.  Geiger's  method  is 
to  make  the  patient  breathe  the  vapor  arising  from  hot  water 
poured  on  unslaked  lime.  Lactic  acid  is  said  (A. Weber)  to  have 
the  same  power. 

From  Dr.  Da  Costa's  monograph  upon  inhalation  I  cite  the 
following  conclusions  as  indicating  the  results  of  experience  upon 
the  subject: — ^ 

"That  in  most  acute  diseases  of  the  larynx,  and  still  more 
so  in  acute  disorders  of  the  lungs,  the  value  of  inhalations  of 
atomized  fluids,  save  in  so  far  as  those  of  water  may  tend  to 
relieve  the  sense  of  distress,  etc.,  and  aid  expectoration,  is  very 
doubtful ;  though  in  some  acute  affections,  as  in  cedema  of  the 
glottis  and  in  croup,  medicated  inhalations  have  strong  claims  to 
consideration. 

"  That  in  certain  chronic  morbid  states  of  the  larynx,  particu- 
larly those  of  a  catarrhal  kind,  and  in  chronic  bronchitis,  they 
have  proved  themselves  of  great  value. 

"  That  in  the  earlier  stages  of  phthisis,  too,  they  may  be  of 
decided  advantage,  and  that  at  any  stage  they  may  be  a  valuable 
aid  in  treating  the  symptoms  of  this  malady. 

"  That  their  influence  on  such  affections  as  hooping-cough  and 
asthma  is  not  satisfactorily  proven. 

"  That  they  furnish  a  decided  and  unexpected  augmentation 
of  our  resources  in  the  treatment  of  pulmonary  hemorrhage. 

"  That  they  require  care  in  their  employ ;  and  that  in  acute 

«  Op.  citat.,  p.  40, 


HYPODERMIC    MEDICATION.  183 

affections  we  should  consider  whetlier,  as  tlioy  have  to  be  used 
frequently  to  be  of  service,  the  ])atient's  strenf^th  justifies  the 
disturbance  or  the  annoyance  their  frequent  use  may  be." 

DOSES  YJJli  INHALATION.' 

Alum 10  to  20  grains. 

Tannin 1  to  20      " 

Perchloride  of  iron  .         .         .         .       ^  to  2        " 

Nitrate  of  silver 1  to  10      " 

Sulphate  of  zinc 1  to  6        " 

Chloride  of  sodium  .         .         .         .       5  to  20      " 

Chlorinated  soda i  to  1  drachm. 

Chlorate  of  potassium    .         .         .         .     10  to  20  grains. 
Chlorate  of  ammonium  .         .         .         .     10  to  20      " 
Watery  extract  of  opium       .         .         .       i-  to  ^        " 
Eluid  extract  of  conium         .         .         .       3  to  8  minims. 

"  "  hyoscyamus         .         .       3  to  10      "■ 

Tincture  of  cannabis  indica  .  .  .  5  to  10  " 
Lugol's  solution  of  iodine  .  .  .  2  to  15  " 
Fowler's  solution  of  arsenic  .         .         .       1  to  20      " 

Tar-water 1  to  2  drachms. 

Oil  of  turpentine 1  to  2  minims. 

To  these  may  be  added,  carbolic  acid  (Marcet)  1  or  2  grains,  or 
creasote,  1  or  2  drops,  in  phthisis ;  and  lactic  acid  (15  to  20  drops 
in  half  an  ounce  of  water),  in  croup.  Also,  nitrite  of  amyl^  2  to 
5  drops;  in  puerperal  convulsions,  angina  pectoris,  etc. 

HYPODERMIC   MEDICATION. 

Apparently  upon  a  suggestion  contained  in  Yalleix's  work  on 
Neuralgia,  Dr.  Alexander  Wood,  of  Edinburgh,  in  1843,  experi- 
mented successfully  with  the  injection  of  anodynes  under  the 
skin  of  parts  affected  with  neuralgic  pain.^  Dr.  Kursak,  of 
Vienna,  disputes  priority  with  him.  Mr.  Rynd,  of  Dublin, 
followed  him  after  about  a  year.  Local  effects,  only,  seem  to 
have  been  clearly  recognized  by  these  gentlemen.  C.  Hunter,  in 
1858,  proved  that  general  effects  upon  the  whole  system  are  pro- 
duced, in  whatever  part  of  the  body  the  injections  are  made. 
Since  1855,  however,  many  medical  men  have  studied  the  sub- 
ject; especially  Behier,  Lorent,  Eulenberg,  and  Nussbaum, 
abroad,  and  Ruppaner  and  Bartholow  in  this  country.  The  prac- 
tice has  now  become  common. 

It  has  been  amply  proved  that  hypodermic  injection  of  medic- 
inal substances  is  ordinarily  entirely  safe  ;  more  rapid,  certain, 
and  exact  in  its  effects,  in  proportion  to  the  amount,  than  medi- 
cation by  the  mouth  ;  that  it  requires  one-third  or  one-half  of  the 
quantity  necessary  when  given  by  the  stomach,  and  produces  less 
complicated  and  generally  less  inconvenient  results. 

The  medicines  principally  used  in  this  way  are  narcotics,  sed- 
atives, nervine  tonics,  and  stimulants.  It  is  in  diseases  or  symp- 
toms affecting  the  nervous  system  that  the  greatest  number  of 

1  From  Da  Costa. 

-  In  1S:>9,  Drs.  I.  Taylor  and  Washington,  of  New  York,  made  subcutaneous  injec- 
tions with  an  Ancl's  syringe,  after  first  incising  ttie  skin. 


184 


GENERAL    THERAPEUTICS. 


The  injection  of 
medicines  into 
the  cellular  tis- 
sue beneath  the 
skin  may  be 
made. 


Generally   -, 


In  Cerebral. 


Spinal. 


and 


Sympatlietic 
nerve-cases, 
inflammatory 
affections,  etc. 


successful  cases  has  been  reported.  Pain,  most  of  all,  is  speedily 
conquerable  by  it.  Hunter  lays  down  the  indications  for  it 
thus ; — 

"  When  the  immediate  and  decided  effect  of  the  medicine  is 
required. 

"Where  medicines  administered  by  the  usual  methods  fail  to 
do  good. 

"  Where  the  effect  of  a  medicine  is  required,  and  the  patient 
refuses  to  swallow. 

"Where,  from  irritability  of  the  stomach,  or  other  cause  (such 
as  idiosyncrasy,  etc.),  the  patient  cannot  take  the  medicine  by 
the  stomach." 

The  following  Table  is  slightly  modified  from  Hunter's  : — 

Locally        f  1.  Caustics  for  nsevi,  aneurisms,  etc. 
with ...   (2.  Anodynes,  for  local  neuralgia. 

Insomnia. 

Melancholia. 

Mania. 

Delirium  tremens. 
i  Hystei'ia. 
I  Chorea. 

[  Central  neuralgia. 
'  Kheumatism. 

Tetanus. 

Hydrophobia. 

Retention  of  urine. 

Convulsions. 

Epilepsy. 
'Peritonitis. 

Pericarditis. 

Dysentery. 

Ophthalmic  surgery. 

Malarial  fever. 

Gangrene. 

Dysmenorrhoea. 

Colic. 

Cholera. 

Sea-sickness. 

Cancer. 

Ulcer  of  stomach. 

Intussusception. 

As  antidote f  For    opium,    bella- 

\      donna,  etc. 
f  With  or  after  chloro- 
Ansesthetic )      fon^    q^    gther  in 

(     operations. 

The  instrument  most  approved  is  a  small  glass  syringe,  holding 
about  half  a  fluidrachm,  and  graduated  for  drops  or  minims,  with 
a  tube  for  puncture,  of  tempered  steel,  or  of  silver  with  a  gold 
point.  The  end  of  the  tube  must  be  small  and  sharp,  and  kept 
very  clean.'     Graduation  of  the  cylinder  is  not  necessary,  as  it  is 

^  Dr.  E.  Cutter,  of  Woburn,  Mass.,  has  had  made  a  syringe  (of  ahiminiiim  alloy)  so 
compact  as  to  be  carried  easily  in  a  pocket  case.  This  is  furnished  by  Shepard  &  Dud- 
ley, William  Street,  New  York.    Celluloid  syringes  also  are  made. 


HYPODERMIC    MKDTCATION, 


185 


easy  to  measure  the  amount  to  be  taken  up  by  it.  Not  much 
pain  is  usually  produced ;  but  sometimes  it  is  quite  severe.  If 
the  dose  of  the  medicinal  agent  be  not  too  large,  the  only  danger 
(unless  in  an  erysipelatous  patient)  is  of  a  circumscribed  inflam- 
mation. Kepeated  injectidns  should  not  be  made  at  exactly  the 
same  spot.  Apart  from  special  local  indications,  the  best  places 
for  injection  are  the  arms,  the  back,  the  abdomen,  the  thighs, 
and  the  calves  of  the  legs.  In  operating,  draw  the  skin  tense 
with  the  forefinger  and  thumb  of  the  left  hand,  and  pass  the 
point  of  the  tube  (first  well  oiled)  quickly  and  steadily  through 
it.  Then  push  in,  not  rapidly,  the  desired  amount  of  the  fluid  ; 
and  withdraw  it  without  rotating  it.  Avoid  subcutaneous  veins  ; 
the  puncture  of  one  of  them  may  give  an  excessive  action  of  the 
medicine.  Intravenous  injection,  however,  is  sometimes  purposely 
employed,  with  proportionate  doses. 

.  The  agents  most  used  are  salts  of  morphia,  atropia,  strychnia, 
and  quinia.  For  anodyne  purposes.  Dr.  Buppaner  prefers  liquor 
opii  compositus,  of  which  one  hundred  drops  are  equal  to  a  grain 
of  sulphate  of  morphia.  Many  use  the  ordinary  solution- of  mor- 
phia (gr.  j  of  morph.  sulph.  in  fgj)  or  Magendie's  (gr.  xvj  in  fgj). 
Doses  (for  adults)  are  as  follows  : — 


Sulphate  of  morphia 
Acetate    "       " 
Sulphate  of  atropia 
Sulphate  of  strychnia   . 
Sulphate  of  quinia 
Hydrochlorate  of  quinia 
Jaborandi,  fluid  extract 
Pilocarpin 

Ergotin .... 
Tinct.  digitalis 
Aconitia 
Apomorphia  . 


gr.  i-i 
gr.  jh—is 
gr.  Sff— tV 
gr.  i — iv 

gr.  I— iii 
f3ss-f3j 

gr.  l-k 
gr.  i — V 
gtt.  V — X 

gr.   2(JtJ — TTTT 

gr.  i\—i 


Practitioners  find  it  best  to  make  always  a,  fresh  solution  of  sul- 
phate or  acetate  of  morphia^  for  hypodermic  use.  Possibly  from 
decomposition  and  the  growth  of  fungi  in  the  liquid,  old  prepa- 
rations are  more  likely  to  be  followed  by  abscess.  Strongly  acid 
and  strongly  alkaline  liquids  are  alike  unsuitable. 

Quinine  is  frequently  dissolved  in  glycerin  for  subcutaneous 
injection.  It  is  apt  to  give  considerable  pain,  however.  Kobner 
advises  using  the  hydrochlorate  (muriate)  of  quinia  for  this  pur- 
pose, its  dose  being  smaller  than  that  of  the  sulphate,  as  it  con- 
tains more  quinia  in  the  same  bulk. 

Among  the  diseases  in  which  palliation  or  relief  of  suffering  is 
often  important  by  means  of  this  method  of  treatment,  are  espe- 

1  Anstie  and  some  other  British  practitioDers  have  preferred  the  acetate  of  morphia, 
freshly  prepared.  Five  grainsof  the  acetate  are  dissolved,  with  uminrmof  acetic  acid,  in 
a  fluidrachm  of  hot  distilled  water.  Two  minims  of  this  will  be  a  dose  to  begin  with. 
Vachell  and  White  have  proposed  the  following:  Acetate  of  morphia,  20  grains;  dis- 
tilled water,  140  minims;  acetic  acid,  5  minims.  T.  &  H.  Smith  advise  meconic  acid 
instead.  Drasche,  Rosenthal,  and  ("onstantin  Paul  recommend  glycerin,  instead  of 
water,  for  hypodermic  injections.  Adrian  prefers  distilled  water  with  twenty  per  cent. 
of  glycerin.  Pellets  for  hypodermic  use  are  now  made.  They  keep  well,  but  are  less 
easy  to  graduate  in  dose  than  solutions. 

16* 


186  GENERAL    THER APE  lTTICS. 

cially  neuralgia,  hysteria,  palpitation  of  the  heart,  cancer,  and 
ulcer  of  the  stomach.  A  case  of  the  latter  affection  is  recorded 
in  which  for  weeks  or  months  the  patient  was  only  able  to  retain 
food  upon  the  stomach  after  the  disposition  to  vomit  had  been 
allayed  by  a  hypodermic  injection  of  morphia. 

Curative  effect  from  anodynes  so  employed  has  been  asserted  in 
cases  of  delirium  tremens,  mania,  and  tetanus;  from  quinine 
(two  to  four  grain  doses)  in  intermittent  fever. 

Tentative  use  of  the  same  mode  of  practice  is  justifiable  in 
cholera,  hydrophobia  (woorara),  poisoning  (as  the  injection  of 
morphia  for  belladonna  poisoning,  and  the  converse),  croup  (apo- 
morphia),  violent  hooping-cough  i^atropia),  pernicious  fever,  spot- 
ted fever,  etc. 

That  the  operation  is  always  without  inconvenience  to  the 
patient  is  not  true.  Not  only  pain,  but  local  inflammation  and 
even  suppuration  may  sometimes  be  induced.  Odevaine,  in  India, 
reports  three  cases  of  tetanus  following  the  hypodermic  injection 
of  quinine.  {Indian  Med.  Gazette,  April,  1871.)^  But  many 
patients,  suffering  painful  complaints,  have  had  a  hundred  or 
more  injections  made  in  different  parts  of  the  body,  without  any 
disadvantage,  and  with  great  relief. 

A  hahit  of  hypodermic  injection  of  morphia  has  often  been 
formed ;  exhibiting  the  same  power  over  the  will  of  the  indi- 
vidual as  tliat  experienced  by  the  opium-eater. 

Hydrate  of  chloral  is  sometimes  used  by  hypodermic  and  also 
(Bucquoy)  intravenous  injection,  especially  in  tetanus.  It  should 
be  diluted  considerably  (ten  grains  to  the  ounce)  to  prevent  local 
irritation.  Intravenous  injection  of  aqua  ammonice  (half  a  flui- 
drachm  with  the  same  or  twice  the  amount  of  water)  has  been 
resorted  to  for  stimulation  in  cases  of  exhaustion  ;  also,  to  antag- 
onize the  poisoning  of  snake  bites  (Halford).  Ether  (15  drops 
at  once)  has  been  given  for  the  same  purpose  by  hypodermic 
injection.  Whisky  and  brandy  may  be  introduced  hypoder- 
mically  in  cases  of  collapse,  in  half  drachm  doses.  Strong  cojfce 
has  also  been  so  used,  and  in  opium  poisoning,  20  or  30  drops  at 
a  time.  Woorara  (curara)  has  been  injected,  with  asserted  suc- 
cess, in  two  or  three  cases  of  hydrophobia.  This  powerful  agent 
has  also  been  hypodermically  applied  in  the  treatment  of  epi- 
lepsy. Acetic  acid  injected  into  cancerous  tumors  is  said  to  have 
some  power  to  cause  them  to  shrink  and  cease  growing.  I  pro- 
pose the  use  of  alcohol  upon  the  same  indication.  I  am  not 
aware  of  its  having  been  thus  employed  ;  but  Politser^  has  so 
treated  polypi  of  the  ear  with  success.  Creasote  may  do  good  in 
like  cases. 

Apomorphia  (grs.  -j\  to  5^)  when  injected  under  the  skin,  pro- 
duces a  powerful  emetic  effect.  It  has  been  used  with  advantage 
in  membranous  croup.     It  is  so  depressing  as  to  require  caution. 

Camphor  (2  or  3  grains,  dissolved  in  ten  times  its  weight  of 

1  other  cases  of  tetanus  following  hypodermic  injections  are  mentioned  in  the  Lon- 
don Lancet,  Dec.  16,  1876,  and  July  6,  1867;  and  Brit.  Med.  Journal.  Nov.  1,  1879.  It 
would  seem  that  a  peculiar  state  of  system  must  be  present,  predisposing  to  tetanus  in 
such  cases. 

2  Wiener  Med.  Wochensehrift,  Nov.  31,  1880. 


TRANSFUSION    OF    BLOOD.  187 

almond  oil)  has  been  found,  when  subcutaneously  injected,  bene- 
ficial in  calming  excitement  and  promoting  sleep  in  lunatics  and 
hysterical  patients. 

Ergot  (or  its  extract,  called  ergotin)  has  been  much  used  of  late 
years,  hypodermically,  to  produce  contraction  of  blood-vessels  and 
other  involuntary  muscular  tissues  ;  as  in  the  treatment  of  hem- 
orrhages^ fibroid  tumors  of  the  uterus^  enlargement  of  the  spleen^  etc. 
Of  ergotin  (which,  as  commonly  prepared,  is  not  the  pure  alka- 
loid, but  a  watery  extract)  Bartliolow'  says,  from  one  to  five 
grains  may  be  injected  at  once  ;  best,  freshly  dissolved  in  distilled 
water,  and  then  passed  through  a  filter.  Of  the  fluid  extract  of 
ergot,  from  five  to  ten  minims  may  be  injected  at  a  time  ;  for 
serious  hemorrhages,  yet  larger  doses.  It  may  be  thus  emplo5'ed 
in  epistaxis,  haemoptysis,  uterine  hemorrhage,  aneurism  of  the 
aorta,  etc.  (It  should  not  be  pushed  so  far  as  to  cause  spasmodic 
closure  of  the  sphincter  of  the  bladder  and  retention  of  urine.) 

Pilocarpin,  hypodermically  injected,  is  the  most  powerful  of 
sudorifics,  increasing  also  largely  the  secretion  of  saliva,  and 
promoting  the  action  of  the  kidneys. 

Hypodermic  alimentation  has  been  tried  in  a  few  cases.  Dr. 
J.  T.  Whittaker,'^  of  Cincinnati,  succeeded  in  keeping  a  patient 
suffering  with  gastric  ulcer  alive  for  several  days  at  a  time  by 
subcutaneous  injections  of  beef  extract,  milk,  and  cod-liver  oil. 
Menzel,  Peres,  Strieker,  and  others  had  before  experimented  simi- 
larly upon  animals,  and  Krueg  successfully  with  olive  oil  upon  an 
insane  patient.* 

Atropia  is  sometimes  hypodermically  injected  in  states  of  great 
prostration,  as  a  ''respiratory  stimulant ;"  and  digitalis  (or  digi- 
talin)  to  "support  a  flagging  heart." 

TRANSFUSION  OF  BLOOD. 

In  states  of  extreme  debility,  as  from  copious  hemorrhage  after 
parturition  or  surgical  injuries,  tlie  introduction  of  fresh  blood  into 
a  vessel  has  been  occasionally  practised  almost  from  ancient  times. 
It  was  performed  for  the  benefit  of  Pope  Innocent  YIII.  near  the 
end  of  the  fifteenth  century.  Sir  Christoplier  Wren  wrote  a  paper 
upon  its  practicability,  for  the  Royal  Society,  in  1657.  Not  much 
later.  Lower  in  England,  and  Denys  in  France,  experimented  with 
it ;  the  latter  with  two  successful  cases  in  human  subjects.  Har- 
wood,  Blundell,  Waller,  Martin,  and  others  afterwards  called 
attention  to  the  same  practice.*  Several  methods  have  been 
employed  ;  the  oldest,  the  transfusion  of  blood  from  an  artery^ 
directly  into  a  vein  of  the  arm  of  the  patient.  In  1872,  Prof. 
Esmarch  performed  arterial  transfusion  twice.  Kolomnin,  of 
Russia,  after  ten  trials,  prefers  injecting  defibrinated  blood  into 
the  peripheral  end  of  tite  radial  artery.^    Mediate  transfusion  of 

1  Materia  Medica  and  Therapeutics,  p.  277.    Squibb's  preparation  is  probably  the  best. 

2 The  Clinic,  Jan.  22,  1876. 

3  Revue  des  Sciences  Medicales,  Jan.,  1876,  p.  106. 

*In  1861,  Dr.  Martin  published  a  statement  of  forty-five  successful  instances  of  trans- 
fusion, out  of  fifty-seven  cases  of  its  performance.  See  N.  Y.  Med.  Record,  April  1, 
1874.  In  all,  126  successful  cases  had  been  reported  down  to  July,  1874,  and  probably 
as  many  or  more  have  occurred  since  that  time,  successful  so  far  as  the  immediale 
result  of  the  operation  is  concerned. 

6  Transactions  of  the  Society  of  Kussian  Physicians,  1879-1880. 


188 


GENEEAli    THERAPEUTICS. 


venous  blood  has  been  most  often  used  ;  the  blood  being  received 
into  an  instrument,  from  which  it  is  again  injected  into  a  vein 
or  (Albanese,  Auter,  Kolomnin,  Asche)  into  an  artery  (radial 
or  posterior  tibial).  On  theoretical  grounds,  defihrinated  blood 
has  been  much  favored,  especially  in  order  to  prevent  inter- 
ference with  the  operation  by  coagulation.  It  would  appear, 
however,  to  be  a  defensible  opinion  that  unwhipped  natural 
blood,  promptly  (though  not  too  rapidly)  transfused,  will  better 
afford  favorable  conditions  for  recuperation.  Introduction  of 
air  during  the  operation  has  been  regarded  as  its  chief  danger  ; 
speedy  death  has  been  ascribed  to  this  accident  in  several  cases. 
Kobin  and  Feltz  have  explained  this  by  capillary  embolism. 
But  Ore  found,  experimentally,  that  a  small  amount  of  air  may 
be  injected  into  the  femoral  vein  of  a  dog  without  injury.  While 
precautions  are  necessary  to  exclude  air,  tliis  risk  need  not  stand 
in  the  way  of  transfusion. 
Altogether,  it  is  probable  that  Aveling's  method  of  immediate 


Fig.  75. 


Dr.  Aveling's  Apparatus  for  Transfusion. 


transfusion  from  vein  to  vein  is  the  best.  The  instrument  for  this 
consists  of  a  small  india-rubber  tube,  about  a  foot  long,  with  a 
bulb  at  the  centre  ;  the  ends  being  furnished  with  canulas  for 
introduction  into  the  veins.  The  movement  of  the  blood  is  facili- 
tated by  pressure  upon  the  bulb.  The  quantity  of  blood  trans- 
ferred has  varied  from  four  to  twelve  or  more  ounces  ;  probably 
from  four  to  six  or  eight  ounces  will  always  suffice.  It  may  be 
sufficiently  well  estimated  in  direct  transfusion,  by  the  time  occu- 
pied. Three  or  four  minutes  will  do  when  blood  flows  from  vein 
to  vein ;  half  a  minute  to  a  minute,  if  from  artery  to  artery. 
Behier^  saved  the  life  of  a  woman  with  twenty  drachms;  using 
Moncocq's  apparatus,  by  which,  at  each  turn  of  the  rack,  five 
grammes  of  blood  are  introduced.  Dr.  J.  W.  Howe  (JV.  Y.  Med. 
Itecord^  April  1,  1874)  has  found  Dieulafoy's  aspirator,  modified 
for  the  purpose,  to  serve  in  transfusion  with  great  convenience. 

1  Eevue  Scieniiflque,  March  7, 1871. 


TRANSFUSION    OF    BLOOD.  189 

Dr.  B.  E.  Fryer,  U.  S.  A.,  has  added  a  second  bulb  to  Aveling's 
apparatus,  for  more  convenient  manipulation  of  the  blood,  which 
requires  some  force  of  pressure  to  secure  its  transmission  {N.  Y. 
Med.  Itecord,  April  15,  1874).  Dr.  T.  G.  Morton  {Am.  Journal  of 
Med.  Sciences,  July,  1874)  reports  success  in  four  cases  with  the 
use  of  defibrinated  blood.  He  has  a  vessel  in  which  the  blood 
can  be  kept  warm,  by  being  surrounded  by  hot  water,  while 
awaiting  use. 

Some  practitioners  prefer  to  omit  the  bidb  of  Aveling's  appa- 
ratus. Others  (McDonnel)  recommend  the  employment  of  a 
funnel  into  which  defibrinated  blood  is  poured,  to  be  conducted 
to  the  vein  through  a  rubber  tube  ending  in  a  cauula.  On  the 
question  of  choice  between  the  use  of  unmodified  and  that  of 
defibrinated  blood,  B.  W.  Richardson  is  among  those  who  urge 
the  latter  ;  Barnes  and  A.  Flint,  Jr.,  as  well  as  Howe  and  Mon- 
cocq,  the  prompt  use  of  unaltered  blood.  During  the  operation 
it  is  advisable  (MacEwen^)  to  have  the  patient's  arm  elevated,  to 
lessen  the  probability  of  air  entering  the  vein  when  it  is  opened 
and  when  the  blood  is  introduced.  For  the  same  reason,  when 
a  syringe  is  used,  a  small  portion  of  blood  may  be  forced  out  after 
it  has  been  filled,  the  nozzle  being  slightly  inclined  upwards. 

The  purpose  of  the  operation  is  of  course  to  sustain  life  until 
the  emergency  which  threatened  exhaustion  is  overpassed,  and 
normal  sanguification  in  the  patient  is  renewed. 

Transfusion  of  blood  has  been  so  far  chielly  employed  in  cases 
of  hemorrhage  from  any  cause,  and,  in  a  few  cases,  for  the  col- 
lapse of  cholera.  Plasse,  Proegler,  and  others,  however,  have 
resorted  to  it,  with  at  least  apparent  temporary  advantage,  in 
advanced  phthisis.'^ 

Experiments  of  the  same  kind,  with  lamb's  blood,  made  at 
Dresden,  by  Drs.  Oehme,  Stetzner,  Hirschfeld,  and  Bischofl',  have 
not  sustained  the  expectation  that  much  benefit  can  be  thus 
effected  in  phthisis.  Immediately  after  the  operation,  in  several 
instances,  shivering,  vomiting,  and  even  convulsions  followed  ; 
a  day  or  two  later,  hsematuria.  All  these  symptoms  soon  disap- 
peared ;  but  the  patient  was  left  with  his  malady  about  as  before. 
Landois,  Ponfick,  Panum,  and  Kuster  have  strengthened  the 
evidence  against  the  employment  of  any  kind  of  blood  except 
that  of  man  ;  that  of  other  animals  being  apparently  dangerous 
in  proportion  to  the  quantity  introduced. 

Dr.  Hodder,  of  Toronto,  in  1850,  used  intravenous  injection 
of  strained  7nilk  in  three  cases  of  cholera,  in  collapse.  Two  of 
these  patients  recovered.  Dr.  J.  W.  Howe,  of  New  York,  in 
1874,  injected  fgvi  of  goat's  milk  fresh  from  the  animal  into  the 
cephalic  vein  of  a  patient  having  phthisis.  During  the  following 
year  Dr.  T.  Gaillard  Thomas^  injected  fgviijs  of  cow's  milk, 
freshly  drawn,  into  the  median  basilic  vein  of  a  woman  exhaust- 
ed after  the  removal  of  a  large  abdominal  tumor.     She  rapidly 

1  London  Lancet,  1880. 

"  Fhila.  Med.  Times,  May,  1874.  See,  also.  Vie  Lamm-blui  Transfusion  beim  Menschen, 
by  Dr.  Oscar  Hasse,  Nordbausen :  Die  Transfusion  des  Blutes,  by  Dr.  Franz  Gesellius ; 
and  an  article  by  Dr.  H.  M.  Madge,  Brit.  Med.  Journal,  Jan.  10,  1874. 

»  Amer.  Journal  of  Med.  Sciences,  Jan.,  1876,  p.  61. 


190  GENERAL    THEE APEUTICS, 

recovered.  Drs.  Howe  and  Dupuy  proved  by  experiments  upon 
dogs  that  milk  an  hour  or  inore  removed  from  the  cow  has  fatal 
eft'ects  ;  it  must  be  fresh  and  alkaline  to  be  successful.  For  cer- 
tainty of  its  alkalinity,  a  small  amount  of  carbonate  of  sodium 
or  ammonium  may  be  added.  Not  more  than  eight  fluidounces 
of  milk  should  be  injected  at  once  ;  four  or  five  ounces  may 
suffice.  The  funnel  and  canulated  rubber  tube  are  preferred  for 
its  introduction.  By  April,  1878,^  Dr.  Thomas  had  operated  in 
this  way  seven  times  upon  human  subjects  ;  with  no  bad  effects 
in  any  instance,  and  in  several  cases  with  prolongation  of  life. 
Meldon,^  of  Dublin,  has  injected  milk  in  ten  cases  ;  four  of  these 
are  reported  as  thus  cured  of  pernicious  ansemia.  Drs.  J.  H. 
Brinton  and  C.  T.  Hunter  of  Philadelphia  have  also  had  suc- 
cessful cases  ;  in  all  to  October,  1879,  twenty-two  cases  were 
recorded.* 

Wulfsberg^*  Demetre-Culcer^  and  Schafer^  object  to  the  trans- 
fusion of  milk,  on  the  basis  of  results  obtained  in  experimenting 
on  animals.  Theoretically,  also,  they  point  out  as  important 
the  absence  of  hcemoglobin  from  milk,  the  diiference  of  milk  corpus- 
cles from  those  of  blood,  the  danger  of  capillary  embolism,  and 
of  bacteria  or  other  "septic  organisms"  being  introduced  with 
milk.  Against  these  objections  stands  the  success  of  the  opera- 
tors above  mentioned,  in  so  considerable  a  number  of  cases ; 
giving  encouragement  to  the  hope  of  Dr.  T.  G.  Thomas,  of  a  use- 
ful future  for  intravenous  lacteal  injection. 

Ponfick,'  Bizzozero  and  Golgi*  have  obtained  promising  results 
with  the  transfusion  of  defibrinated  blood  into  the  peritoneal  cav- 
ity. After  experimenting  with  animals,  Ponfick  resorted  to  this 
practice  with  three  hospital  patients.  Slight  feverishness  and 
abdominal  tenderness  occurred,  but  soon  passed  away.  The 
apparatus  used  was  an  india-rubber  tube,  to  one  end  of  which 
a  glass  tube  was  attached,  and  to  the  other  a  pen-pointed  canula, 
which  could  be  closed  with  a  tap.  First  filling  the  whole  tube 
with  defibrinated  blood,  the  canula  was  pushed  through  the 
abdominal  wall,  the  tap  opened,  and  the  blood  poured  into  the 
peritoneal  cavity.  From  220  to  350  grammes  (7  to  nearly  9 
ounces)  were  injected  at  one  operation,  without  pain  or  great 
discomfort.  Immediate  increase  of  the  red  blood  corpuscles  in 
the  blood  of  the  subject  of  transfusion  was  ascertained,  and 
this  lasted  more  than  a  week.  Absence  of  danger  to  the  brain, 
lungs,  or  heart  is  urged  on  behalf  of  this  procedure.  Of  course 
there  is  a  possibility  of  peritoneal  inflammation  ;  and  the  value 
belonging  to  the  operation  will  have  to  be  finally  determined  by 
more  extended  experience. 

The  inconvenience  attending  all  modes  of  transfusion  is  likely 
to  cause  them  to  be  reserved  very  much  for  extreme  emergencies. 

(On  Pneumatic  Aspiration,  see  p.  112.) 


1 N.  Y.  Med.  Record,  April,  1878.  2  Lancet,  April,  3, 1880. 

8  Medical  Press  and  Circular,  October,  1879.  *  Lancet,  Dec.  7,  1878. 

B  These  de  Paris,  3  Mai,  1879. 

sTransac.  of  Obstet.  Society  of  London,  1879. 

1  Medicinisch  Rundschau,  1879.  p.  876. 

8(Jentralblatt  f.  Medicin.  Wissenschaft,  Dec.  20, 1879. 


THERAPEUTIC    MAXIMS.  191 

GENERAL  CONCLUSIONS. 

The  following  may,  in  recapitulation,  be  stated  to  be  the  most 
general  desiderata  in  the  management  of  all  diseases: — 

■Rp  f   f  ft,  in  all  acute  diseases  ; 
iteSb  I  ^^  jj^  ^Y\  cases  of  exhaustion. 

P  ,  fa,  of  the  j^mV?s  and  solids  ; 

ijaiance  |  ^^  ^f  ^^^q  activity  o[  functions. 

T>T  1  VI     J    v  f  a,  due  removal  of  exci'ch'ons: 

Normal  blood-change  |  ^'  ^^^^^^^^  of  movhid  poisons. 

q  „_„_*  S  ^1  i^  fiii  asthenic  cases  ; 
Dupport  ^  j^^  j^j^  ^^^g^  siages  of  sthenic  cases. 

THERAPEUTIC  MAXIMS. 

1.  All  pathology  is  but  the  physiology  of  organic  perturba- 
tions. 

2.  Never  interfere  actively  in  disease  without  a  distinct  object. 

3.  Act  only  upon  scientific  reason,  or  well-defined  experience. 

4.  Treat  the  cause  of  disease  whenever  it  is  possible. 

5.  Watch  always,  and  treat,  when  requisite,  the  condition  of 
the  patient. 

6.  Avoid,  especially,  routine  treatment  according  to  the  names 
of  diseases. 

7.  Use  no  violence  with  self-limited  diseases. 

I  believe  that  a  sound  "theory  of  medicine"  may  be  approxi- 
mated in  a  single  para:^rapli,  thus : — 

Physiological  optimism  characterizes  the  aggregate  tendency 
of  all  the  forces  of  the  living  organism,  under  the  influence  of  life- 
force.  But,  the  best  possible  result  in  a  given  case  may,  from  its 
conditions  and  circumstances,  fall  far  short  of  health.  Medicine, 
then,  is  to  favor  or  supply  those  conditions  which,  under  natural 
laws,  alloiv  or  promote  the  best  result. 

In  aiming  to  fulfil  this  duty,  the  art  of  healing  must  always 
depend,  in  part,  upon  empirical  observation  (which  every  branch 
of  knowledge  requires)  and  in  part  upon  deductive  science.  But 
in  both  alike,  the  physician  is,  or  should  be,  "naiwrce  minister  et 
inttrpres.''^ 


192  ■  NOSOLOGY. 


SECTION  IV. 

NOSOLOGY. 

Diseases  were  by  Cull  en  classified  as  locales,  pyroses,  eachexise, 
and  neuroses  (local  diseases,  fevers,  cachectic  diseases,  and  nervous 
aftectious). 

The  advances  made  in  pathology  since  Cullen's  time  require 
some  modification  of  this  arrangement,  while  retaining  its  princi- 
ple.    I  propose,  therefore,  that  diseases  be  sub-divided  as — 

Phleg'inasiae :  inflammations. 
Zymoses :  zymotic  diseases. 
Cachexise :  cachectic  affections. 
Neuroses :  nervous  disorders. 
Ataxias :  unclassifiable  diseases. 

The  following  list  is  intended  to  present  only  the  most  important 
diseases  of  each  class : — 

Phlegmasiae : 

Laryngitis ;  G-astritis ; 

Tracheitis ;  Enteritis ; 

Bronchitis ;  Dysentery ; 

Pneumonia ;  Peritonitis  ; 

Pleurisy  ;  Hepatitis  ; 

Endocarditis ;  Nephritis  ; 

Pericarditis ;  Meningitis ; 

Stomatitis ;  Cerebritis ; 

Pharyngitis ;  Myelitis. 

Zymoses  (diseases  produced  by  a  morbid  poison ;  enthetic) : 
Only  produced  by  contact  or  inoculation — 

1.  Primary  Syphilis  ;  3.  Hydrophobia  ; 

2.  Gonorrhoea;  4.  Vaccinia. 

Eruptive — contagious — 

1.  Variola  ;  4.  Morbilli  (measles) ; 

2.  Varioloid  ;  5.  Eotheln ; 

3.  Varicella  ;  6.  Scarlatina. 

Contagious — not  eruptive — 

1.  Parotitis  Contagiosa  (mumps) ; 

2.  Pertussis  (hooping-cough). 

Generally  epidemic  or  endemic — 

1.  Typhoid  Fever  ;  6.  Plague  ; 

2.  Typhus  ;  7.  Cholera  ; 

3.  Cerebro-spinal  Fever  ;         8.  Endemic  Dysentery  ; 

4.  Puerperal  Fever  ;  9.  Influenza  ; 

5.  Erysipelas  ;  10.  Diphtheria. 


NOSOLOGY. 


193 


Endemic,  occasionally  epidemic — 

1.  Yellow  Fever ; 

2.  Relapsing  Fever ; 
"Malarial;"  endemic — 

4.  Intermittent ; 
Kemittent ; 

Cachexiae : 
1.  Diatheses  (general  cachexiae): 
Always  chronic — 


3,  Dengue, 


Pernicious  Fever. 


a.  SpaiicTemia  (ansemia); 

h.  Hemorrhagic  Diathesis ; 

h.    Chlorosis  ; 

i.    Tuberculosis  ; 

c.    Leucocythpemia ; 

j.    Diabetes ; 

d.   Pseudo-leukeemia ; 

k.   Lithiasis; 

e.    Pernicious  Anaemia ; 

I.    Secondary  Syphilis  ; 

/.    Melanremia ; 

m.  Addison's  Disease  ; 

(J.   General  Dropsy  ; 

n.  Exophthalmic  Goitre. 

Acute  Oi*  subacute— 

u.  Scurvy; 

d.  Septaemia ; 

6.   Gout ; 

e.   Pyaemia  ; 

c.   Eheumatism ; 

/.    Mucous  Disease. 

2.  Local  cachexia}  (degenerations): 

Cancer ; 

Bright's  Disease  (of  the  Kid- 

Various   Tumors,    Cysts, 

ney); 

etc.; 

Fatty  Degeneration  of  the 

Goitre  ; 

Heart ; 

Cirrhosis    (of    the    liver, 

Other    organic     Degenera- 

etc.); 

tions. 

Skin  diseases, viz.: 

Exanthemata     (urticaria, 

Hypertrophiae      (elephanti- 

roseola); 

asis,  etc.); 
Tubercula(molluscum,  etc.); 

Papulae  (lichen,  etc.); 

Vesiculae  (herpes,  etc.); 

Hemorrhagise  (purpura); 

Bullae  (pemphigus,  etc.); 

Neuroses  (prurigo); 

Pustulae  (impetigo,  etc.); 

Parasiticae  (scabies,  etc.); 

Squanuc  (psoriasis,  etc.); 

Syphilida. 

Maculae  (fuscedo,  etc.); 

Neuroses : 

Apoplexy ; 

Cerebro-spinal  Sclerosis ; 

Paralysis ; 

Laryngismus  Stridulus ; 

Epilepsy; 

Convulsions ; 

Catalepsy ; 

Neuralgia ; 

Hysteria ; 

Delirium  Tremens ; 

Chorea ; 

Insanity ;  viz. : 

Tetanus ; 

Mania ; 

Asthma ; 

Monomania ; 

Angina  Pectoris ; 

Melancholia ; 

Locomotor  Ataxy ; 

Dementia. 

Ataxiae  (unclassifiable  Diseases) : 

Hemorrhages  ; 

Cholera  Morbus ; 

Local  dropsies  (ascites,  etc.); 

Colic ; 

Jaundice ; 

Diarrhoea ; 

Dyspepsia ; 

Worms,  etc. 

17                                          N 

PART  11. 

SPECIAL  PATHOLOGY  AISTD  PRACTICE 
OF   MEDICINE.^ 


HAVIITG  endeavored,  on  our  previous  pages,  to  state,  with 
brevity,  what  may  be  regarded  as  the  essential  principles 
of  the  science  of  medicine,  we  proceed  to  apply  these  to  an  account 
of  the  diseases  to  be  dealt  with  in  practice.  Our  purpose  will  be 
to  give  a  brief  and  clear  description  of  each  disease,  with  its  causa- 
tion, diagnosis,  pathology,  and  treatment. 

The  classification  of  diseases  followed  in  the  succeeding  pages 
is  chiefly  clinical ;  though  based  upon  the  pathological  nosology 
already  stated  (Part  I.,  Sect.  TV.).  Such  an  arrangement  finds 
suflicient  justification  in  its  convenience. 

AFFECTIOKS  OF  THE  EESPIEATORY  ORGAN'S. 
PNEUMONIA. 

Definition. — Inflammation  of  the  substance  of  the  lung. 

Varieties.  —  According  to  its  seat;  single,  double,  lobular. 
According  to  causation  ;  idiopathic,  from  cold  and  wet ;  traumatic, 
from  injury ;  caseous  or  tuberculous,  in  phthisis  ;  and  typhoid 
pneumonia.  Except  in  phthisis,  we  seldom  meet  with  chronic 
pneumonia ;  what  is  commonly  called  so  being  mostly  induration 
following  acute  pneumonia  as  an  efiect,  not  a  continuation  of  it. 

Symptoms  and  Course. — A  chill  or  stage  of  depression,  followed 
soon  by  fever,  with  oppression  in  breathing,  dull  pain  (not  always 
present)  in  the  chest,  and  sometimes  short  cough.  Delirium  is 
common.  In  children,  vomiting  frequently  occurs.  Temperature 
of  the  body  is  high,  especially  on  the  fourth  or  fifth  day  ;  some- 
times, in  the  evening,  reaching  104°  or  105°  Fahr.  in  the  axilla. 
Secretions  scanty,  as  in  other  febrile  states.  Urine  containing  an 
excess  of  urea,  but  deficient  especially  in  the  chlorides,  in  the 
middle  period  of  the  attack.  Expectoration  commences  about 
the  third  day  usually,  the  sputa  being  composed  of  mucus,  lymph, 
and  blood  mixed  together,  making  the  rusty  sputum  of  pneumonia. 
In  this  an  excess  of  chloride  of  sodium  will  be  found  by  testing 
with  nitrate  of  silver. 

INOTE  TO  Paet  II. — The  letter  F,  followed  by  a  number,  in  parenthesis,  indicates  a 
reference  to  a  formula  of  that  number,  in  the  latter  part  of  the  book.  See,  also.  Index 
of  Formulae,  at  the  end  of  the  book. 

194 


PNEUMONIA 


195 


Fig.  76. 


The  hcif^ht  of  the  attack  is  generally  reached  between  the  fifth 
and  the  seventh  day  ;  after  which  the  temperature  declines,  and, 
in  favorable  cases,  all  the  symptoms  subside.  In  others,  oppres- 
sion in  breathing,  and  prostration  increase  ;  cough  deepens,  and 
expectoration  becomes  more  abundant,  at  last  purulent.  Death 
seldom  occurs  before  the  sixth,  and  may  be  as  late  as  the  twentieth 
day. 

Stages.— 1st.  that  of  congestion  or  engorgement,  and  the  com- 
mencement of  exudation  ;  2d,  that  of  exudation  and  red  hepati- 
zation ;  ;kl,  that  of  gray  hepatization,  softening,  or  purulent 
infiltration. 

Physical  Signs.— These  differ  in  the  three  stages.  In  the  first 
they  are,  moderate  dulness  of  resonance  on  percussion  over  the 
affected  lung,  and,  on  auscultation,  after  the  first  day  or  two,  the 
fine  crepitant  rale. 

In  the  second  stage,  decided  dulness  on  percussion,  no  rille,  but 
instead,  bronchial  respiration  and  bronchophony  ;  with  increased 
vocal  fremitus.  In  the 
stage  of  softening  or 
suppurative  i  n  fi  1 1  r  a- 
tion  (gray  hepatiza- 
tion), dulness  on  per- 
cussion, and  coarse  crep- 
itant or  mucous  rale. 

When  resolution  fol- 
lows the  second  stage, 
as  in  cases  of  recovery, 
the  bronchial  respira- 
tion gives  way  to  re- 
turning fine  crepitation 
(crepitus  redux);  and, 
then,  the  dulness  of 
resonance  on  percus- 
sion also  gradually  dis- 
appears. 

Terminations. — Besolution ;  death  in  the  second  stage  from 
asphyxia ;  death  from  exhaustion  in  the  third  stage  ;  recovery 
after  the  third  stage  (uncommon);  abscess  ;  gangrene  of  the  lung. 

Complications. — Pleurisy  (pleuro-pneumonia) ;  capillary  bron- 
chitis ;  tubercle  ;  inflammation  of  the  liver ;  endemic  malarial 
fever. 

Sequelae. — The  most  frequent  is  that  persistent  consolidation 
of  the  lung  called  by  some  chronic  pneumonia.  Tubercular 
deposit,  sometimes  even  acute  phthisis,  may  follow  pneumonia, 
in  persons  predisposed  to  it. 

Morbid  Anatomy. — The  loicer  or  middle  lobe  is  almost  always 
the  seat  of  the  disease.  Should  death  take  place  (as  it  rarely 
does)  in  the  first  stage,  the  lung  would  be  found  somewhat  swollen, 
dark-red,  inelastic  (splenization),  and  filled  with  blood  or  bloody 
serum.  It  would  still  float  in  water,  though  heavier  than  healthy 
lung.     It  is  easily  torn. 

In  the  second  stage,  of  hepatization,  the  lung  is  no  longer 
spongy,  but  presents  considerable    resemblance  to  the  liver ; 


Eed  Hepatization  (magnified). 


196      DISEASES  OF  ORGANS  OF  RESPIRATION. 

although  a  finger  may  be  easily  thrust  through  it.  When 
entirely  hepatized,  it  will  not  float  in  water,  the  air  being  dis- 
placed from  the  cells  by  the  exudation  of  coagulable  lyniph. 

The  third  stage  consists  in  the 
Fig.  77.  degeneration   (in  the    absence 

of  more  favorable  resolution  by 
absorption)  of  the  exudation. 
This  occurs  by  granulation,  soft- 
ening, and  suppuration.  Mostly 
the  latter  is  infiltrated ;  occa- 
sionally an  abscess  forms.  In 
gray  hepatization,  the  lung  is 
sohd,  impermeable  to  air,  with 
a  granite-like  appearance  of  red 
and  white  points  on  section.  It 
sinks  in  water,  but  is  more  easily 
torn,  or  crushed  into  a  pulp, 
than  in  the  second  stage.  Caseous 
pneumonia  is  now  regarded  by  many  as  a  frequent  beginning  of 
phthisis ;  the  exudation  neither  being  absorbed  (resolution)  nor 
converted  into  pus,  but  undergoing  a  slow  cheesy  degeneration  ; 
corresponding  with  what  has  been  hitherto  called  "  tuberculous 
infiltration." 

Fig.  78. 


Lung-tissue  in  Red  Hepatization. 


>6  4     X  <1^ 


/ 

y 


Elements  of  Gray  Hepatization.     (Da  Costa.) 

Chronic  pneumonia,  of  authors,  is  rather  a  sequela  of  the  inflam- 
matory affection ;  consisting  in  induration  or  consolidation  of  the 
affected  portion  of  lung,  the  exudation  not  undergoing,  for  a  con- 
siderable time,  either  absorption  or  degeneration.  It  is  not  fre- 
quent, in  the  absence  of  tubercular  deposition.  This  was,  at 
least,  the  opinion  of  Laennec,  sustained  also  by  Grisolle,  Chomel, 
Stokes,  Niemeyer,  and  other  authorities.  Wilson  Fox,  however,^ 
identifies  cirrhosis  of  the  lung  with  chronic  pneumonia.     Walshe, 


1  See  Cirrhosis  of  the  Lung,  p.  200  of  this  book  ;  also,  artiole  on  Chronic  Pneumonia, 
in  Reynolds'  System  of  Medicine,  Amer.  Edition,  Vol.  II. 


PNEUMONIA.  197 

Corrifjan,  Bastian,Wilks,  and  others,  regard  pulmonary  cirrhosis 
as  a  disLiuct  aUcctiou. 

Diagnosis. — The  only  affections  with  which  pneumonia  is 
likely  to  be  confounded  are  pleurisy,  bronchitis,  and  phthisis. 
In  children,  collapse  of  the  lung  has  been  mistaken  for  lobular 
pneumonia. 

From  pleurisy,  pneumonia  is  known  by  the  absence  of  the  sharp 
pain  belonging  to  the  former,  and  by  the  crepitant  rule  and  rusty 
sputa.  From  bronchitis,  by  the  dulness  on  percussion,  crepitant 
rale,  bronchial  respiration,  and  bronchophony.  From  phthisis, 
by  its  sudden  onset,  tine  crepitation,  and  sputa,  as  well  as  by  the 
acute  violence  of  the  attack.  Latent  pneumonia  sometimes  com- 
plicates fevers,  etc. 

Prognosis. — Simple  pneumonia,  of  one  lung,  in  a  young  and 
previously  healthy  person,  ought,  under  favorable  circumstances 
and  judicious  treatment,  always  to  be  recovered  from.  In  the 
aged,  it  is  dangerous ;  and  double  pneumonia  is  so  at  all  periods 
of  life,  though  good  recoveries  do  occur.  It  is  double  in  about 
one  case  in  eight. 

Pathology  and  Nature. — Ordinary  pneumonia  is  a  phlegmasia; 
with  the  usual  elements  of  general  pyrexia  or  fever,  local  hyper- 
semia,  and  local  exudation.  As  in  other  phlegmasise,  the  rela- 
tion of  these  to  each  other  is  not  easily  determinable.  Is  the 
local  affection  always  the  first  thing,  causing  the  fever,  or  is  there 
a  blood  disease  first,  producing  both  the  fever  and  the  local  affec- 
tion ?  In  traumatic  pneumonia,  it  is  plainly  the  former.  In 
other  cases,  after  exposure  to  cold  and  wet,  we  may  suppose  it  to 
be  both ;  but  the  primary  step  of  the  actual  inflammation  is  prob- 
ably the  local  disturbance  in  circulation,  functional  action,  and 
nutrition. 

Causation. — As  already  intimated,  cold,  suddenly  or  partially 
applied  to  the  body,  especially  to  the  chest,  is  the  most  common 
cause  of  pneumonia.  But  the  previous  state  of  the  health,  and 
especially,  also,  latent  tubercle,  may  predispose  to  it.  So,  in  cer- 
tain regions,  does  the  influence  of  malaria. 

Some  writers  have  latterly  maintained  that  pneumonia  is, 
ordinarily,  a  "fever"  or  self-limited  constitutional  disease  (not  a 
true  phlegmasia  or  idiopathic  local  inflammatory  affection).  While 
there  is  no  doubt  at  all  that  inflammation  of  the  lungs  frequently 
complicates  malarial,^  typhoid,  and  other  fevers,  my  belief  is 
decided  that  the  large  majority  of  cases  of  pneumonia  are  simply 
inflammatory,  as  truly  as  pleurisy  or  other  phlegmasice.  The 
"  pneumonic  fever"  theory  seems  to  me  to  have  influenced  treat- 
ment disadvantageously. 

Treatment. — This  remains  to  be  a  qucestio  vexata.  Having  con- 
sidered already  (General  Therapeutics)  the  principles  involved, 
my  conclusions  may  be  briefly  stated.  I  am  convinced  by  expe- 
rience that  prompt  and  moderate  "antiphlogistic"  treatment 
may  greatly  lessen  the  danger  of  pneumonia,  if  not  shorten  its 
duration. 

Probably  nine  cases  in  ten  would  recover  without  the  abstrac- 

1  See  La  Roche  on  Pneumonia  and  Malaria. 
17* 


198      DISEASES   OF  ORGANS   OF   RESPIRATION. 

tion  of  blood ;  the  tenth  might  die  for  want  of  it.  I  believe  that 
the  mortality  of  pneumonia  has  increased  in  Philadelphia  and 
elsewhere  since  bloodletting  has  been  so  g^erally  abandoned.^ 
But  bleeding  from  the  arm,  if  resorted  to,  should  be  done  but 
once;  not  later  than  the  third  or  fourth  day ;  and  it  may  be  mod- 
erate in  amount.  Old  persons  and  those  of  feeble  system  will 
neither  bear  nor  require  it. 

Cupping  between  the  shoulders  may,  in  many  cases,  take  the 
place  of  venesection ;  in  some,  it  may  follow  this.  The  early 
administration  of  a  vigorous  purgative,  as  Epsom  salts,  or  citrate 
of  magnesium,  is  proper  in  the  absence  of  any  special  contraindi- 
cation. 

Tartar  emetic  [F.  1]^  in  the  dose  of  one-eighth  to  one-quarter 
of  a  grain  for  an  adult,  every  two  or  three  hours,  may  be  con- 
tinued during  the  height  of  the  febrile  stage.  For  this,  as  for 
bleeding,  the  indications  are  to  be  found  not  in  the  physical  signs 
of  pneumonia,  but  in  the  general  condition  of  the  system ;  not 
in  the  crepitant  rale,  but  in  the  hot  skin,  hard  or  else  oppressed 
pulse,  pain  and  dyspnoea,  and  more  or  less  darkly  flushed  face. 
After  the  height  of  the  attack,  small  doses  of  ipecacuanha  [F.  5] 
may  be  substituted  for  the  antimonial ;  or  nitrate  of  potassium 
[F.  4] ,  gr.  X,  every  two  hours.  Some  practitioners  (as  J.  Lewis 
Smith)^  give,  in  place  of  antimony,  tincture  of  veratrum  viride, 
in  small  doses,  watching  its  effects,  and  withdrawing  it  when  the 
pulse  has  been  sufficiently  reduced.  Murchison  sometimes  uses 
tincture  of  aconite,  with  liquor  ammonii  acetatis.  Dr.  Gehrun^, 
of  Colorado  [St.  Louis  Med.  and  Surg.  Journ..,  November,  1873), 
urges  the  importance  of  rest  to  the  inflamed  lung;  which  he 
endeavors  to  secure  by  passing  a  broad  bandage  around  the  chest, 
over  a  layer  of  cotton  batting.  Where  but  one  lung  is  affected,  the 
idea  seems  reasonable.  A  broad  piece  of  adhesive  plaster^  unilater- 
ally applied  (Eoberts),  will  answer  as  well  for  the  same  purpose. 

Asthenic  pneumonia  requires  a  different  treatment ;  and  the 
same  will  apply  to  the  third  or  suppurative  stage  of  all  cases. 
Support  may  be  required,  in  a  few  cases,  even  from  the  first ;  by 
beef-tea,  wine  or  spirits  (best  with  nourishment,  as  in  milk  punch), 
quinine  [F.  2],  or  ammonia  [F.  3].  In  hospital,  I  have  known 
more  than  one  case  to  recover  under  this  plan  alone;  but  they  are 
the  exceptions.*  Some  cases  in  which  bleeding  or  cupping  will  be 
proper  in  the  first  stage  before  the  fourth  day,  may  require  beef- 

1  The  late  Dr.  L.  P.  Gebhard,  of  Philadelphia,  informed  me,  that  in  a  large  practice, 
of  more  than  half  a  century,  he  had  never  lost  a  case  of  simple  pneumonia;  his  treat- 
ment being  (according  to  cases)  "  moderately  antiphlogistic,"  as  above  described.  Those 
■who  object  to  venesection  in  all  cases  of  pneumonia,  do  so,  almost  invariably,  on  theo- 
retical grounds,  without  having  tried  it.  Its  occasional  use  is  justified  with  almost  equal 
unanimity,  by  those  who  have  had  experience  with  it.  This  was  well  brought  out  in  a 
discussion  of  the  subject  at  Richmond,  Va.,  1881 ;  the  "net  result"  of  which  was  thus 
expressed  by  Dr.  Martin,  of  Boston  :  "  I  trust  that  it  may  go  out  to  the  world  that  the 
American  Medical  Association  sanctions  the  occasional  use  of  the  lancet,  at  least." 

2  F.,  with  a  number,  in  brackets,  refers  to  a  formula  in  the  collection  at  the  end  of 
the  book. 

s  On  the  Diseases  of  Infancy  and  Childhood:  Philadelphia,  1870 

*  Dr.  A.  Patton,  of  Indiana,  reports  the  treatment,  by  himself  and  others,  of  three 
hundred  and  nine  cases  of  pneumonia,  of  all  grades,  with  carbonate  of  ammonium  ;  ."5 
to  10  grains  every  two  hours,  night  and  day ;  little  other  treatment  being  used,  The 
number  of  deaths  was  eight,  or  one  in  thirty-eight  cases. — Am.  Journ.  of  Med.  Sciences, 
October,  1870,  p.  374. 


PNEUMONIA.  199 

tea  in  the  second  stage,  and  moderate  stimulation  later.  A  large 
blister  over  the  aflected  part  is  often  useful  about  the  fifth,  sixth, 
or  seventh  day  of  the  attack. 

Dr.  A.  Flint'  considers  that  twenty-grain  doses  of  quinine, 
given  early,  may  abort  some  attacks  of  pneumonia.  He  believes 
also  that,  in  any  case,  "if  it  does  no  good  it  does  no  harm;" 
and  advises  resorting  to  the  use  of  quinine  in  all  cases  of  pneu- 
monia. Supposing  this  to  be  allowable  in  many  cases  treated 
in  hospitals^  1  am  by  no  means  convinced  that  it  will  answer  well 
in  all  cases  met  with  in  private  practice.  Dr.  Everett  (N.  Y. 
Med.  Kecord,  Sept.  10,  1881)  has  treated  cases  successfully  with 
continuous  inhalation  of  cold  aii\  brought  through  a  tube  from  out 
of  doors  in  winter. 

Varieties  of  Pneumonia. — When  comphcated  with  pleurisy  or 
bronchitis,  no  important  modification  of  treatment  is  called  for. 
Tuberculous  pneumonia  requires  careful  husbanding  of  the  re- 
sources of  the  economy.  Loss  of  blood  is  then  rarely  proper  ;  if 
at  all,  it  must  be  local  only,  and  in  minimum  quantity.  The 
necessity  for  the  analeptic  treatment  of  the  tubercular  diathesis 
is  paramount.  Dry  cups,  blisters,  and  counter-irritant  plasters, 
or  tincture  of  iodine,  croton  oil  or  tartar  emetic  ointment  exter- 
nally applied,  are  then  suitable.  Warm  poultices,  as  of  Indian  or 
flax-seed  meal,  with  or  without  the  addition  of  mustard  ;  or  carded 
wool,  covered  by  India-rubber  or  oiled  silk,  kept  on  the  chest  day 
and  night  for  a  time,  are  often  very  useful,  especially  in  children. 

Traumatic  pneumonia,  following  an  injury,  is  not  common, 
except  in  army  practice.  It  calls  for  no  particular  difference  of 
treatment. 

Typhoid  pneumonia  is  a  term  not  always  uniformly  applied. 
It  means,  with  some  authors,  inflammation  of  the  lungs  compli- 
cating typhoid  fever ;  others  include  under  it  all  cases  of  asthenic 
pneumonia.  More  generally,  however,  it  designates  that  form  of 
the  disease  in  which  epidemic  or  endemic  influence  has  impressed 
a  peculiar  character.  Malarial  regions  especially  exhibit  this,  in. 
the  "winter  fever  "or  typhoid  pneumonia  of  our  Southern  States. 
Early  and  great  debilitj^,  out  of  proportion  to  the  local  symptoms, 
with  a  tendency  to  low  delirium,  and  to  remittence,  mark  this 
disorder.  In  treatment,  it  bears  little  or  no  depletion,  hardly  even, 
the  reduction  of  excitement  by  tartar  emetic  or  veratrum  viride. 
Diaphoretics  first,  as  [F.  6]  ipecac,  2  grain,  with,  perhaps,  the  same 
amount  of  calomel  and  five  or  ten  grains  of  nitrate  of  potassium, 
every  three  hours ;  or  liquor  ammonii  acetatis  [F.  7] ,  or  solution 
of  acetate  of  potassium  [F.  8] ;  then  quinine,  when  the  need  of  a 
tonic  is  apparent,  which  may  be  very  early  ;  with  strong  liquid 
nourishment,  in  a  few  cases  stimulants,  and  moderate  counter- 
irritation  :  these  are  the  measures  usually  proper  in  typhoid 
pneumonia. 

After  recovery  from  an  attack  of  inflammation,  the  lung  will 
be  for  some  time  more  than  usually  susceptible  to  conditional 
changes.  Exposure  should,  then,  be  carefully  avoided  ;  and  flan- 
nel ought  to  be  worn  next  the  skin.     In  winter  a  mild  warming 

1  Philadelphia  Medical  Times,  June  3,  1880,  p.  158, 


200      DISEASES   or   ORGANS  OF   RESPIRATION. 

plaster,  as  of  hemlock  or  Burgundy  pitch,  over  the  chest,  wili 
give  good  protection. 

CIERHOSIS  OF  THE  LUNG. 

Definition. — A  slow,  chronic  affection,  with  cough  and  muco- 
purulent expectoration,  not  unfrequently  hemorrhages,  but  with 
little  or  no  wasting  of  the  body  ;  in  which,  as  ascertained  after 
death,  the  lung  involved  is  shrunken  (sometimes  to  but  one-fourth 
of  its  normal  size),  with  obliteration  of  its  air-vesicles,  by  conver- 
sion of  the  parenchyma  into  a  fibroid  material ;  the  bronchial  tubes 
also  being  dilated,  and  the  lung  on  the  other  side  much  enlarged. 
As  physical  signs,  may  be  noticed  high-pitched  percussion  reso- 
nance ;  sometimes  amphoric  resonance  over  a  much  dilated  bron- 
chial ramification  ;  occasionally,  bronchophony  ;  on  auscultation, 
feeble  or  absent  respiratorj'^  sound  at  the  apex  of  the  afiected 
lung ;  tubular  respiration  in  various  degrees  elsewhere  on  the 
afiected  side.  Mucous  rales  are  not  uncommon.  After  several 
months ,  shrinking  of  the  side  of  the  chest  affected  occurs.  The  posi- 
tion of  the  heart  is  altered  by  the  gradual  shrinking  of  the  lung  ; 
the  heart  being,  so  to  ^peak,  moved  toward  that  side. 

Synonyms. — Chronic  pneumonia ;  interstitial  pneumonia;  sclero- 
sis of  the  lung;  fibroid  plithisis. 

Pathology. — Difierent  opinions  have  been  the  following :  1. 
That  of  Laennec,  that  the  consolidation  of  the  lung  results  from 
chronic  catarrh,  with  accumulation  of  mucus  and  pressure  of 
dilated  bronchial  tubes.  2.  C.  J.  B.  Williams'  view,  that  it  is  a 
sequela  of  pleuro-pneumonia.  3.  Charcot's  and  W.  Pox's  opinion, 
that  it  is  identical  with,  or  the  result  of,  chronic  pneumonia.  4. 
The  judgment  of  J.  Hughes  Bennett,  that  it  is  a  phase  of  tuber- 
cular disease,  advancing  towards  recovery.  5.  Corrigan's  and 
Bastian's,  that  it  is  analogous  to  cirrhosis  of  the  liver  ; — the  char- 
acteristic change  being  the  interstitial  growth  or  deposit  of  a 
fibroid  tissue  ;  a  fibroid  substitution  or  degeneration,  whether 
preceded  or  not  by  acute  or  chronic  inflammation.^ 

Practically,  tlie  most  important  question  in  regard  to  cirrhosis 
of  the  lung  is,  as  to  its  independence  of  tubercular  deposit,  and 
the  tubercular  diathesis.  I  believe  that  the  occurrence  of  a  true 
fibroid  degeneration  of  the  lung,  independent  of  tuberculosis,  has 
been  proved  ;  but  such  cases  are  not  frequent. 

Indications  for  the  treatment  of  pulmonary  cirrhosis  are  those 
of  relief  of  the  symptoms  as  they  present  themselves,  along  with 
hygienic  management  and  general  support  of  the  energies  of  the 
system.  For  the  cough,  remedies  applicable  to  chronic  bronchitis 
will  be  in  place  ;  including  the  inhalation  of  tar  vapor,  creasote, 
or  (JSTiemeyer)  spirits  of  turpentine.  Iodide  of  potassium,  and  the 
external  application  of  tincture  of  iodine,  are  advised  with  a  view 
towards  the  dissipation  by  absorption  of  the  deposited  fibroid 
material.  Of  this,  however,  we  cannot  be  sanguine  in  any  case  ; 
although  retardation  of  the  degenerative  process  is  not  improb- 
able. 

1  See  Bastian's  article  on  Cirrhosis  of  the  Lung,  in  Reynolds'  System  of  Medicine, 
Amer,  edition,  VoL  II, 


PLEURISY.  201 


PLETJKISY. 


Definition. — Inflammation  of  the  pleura. 

Varieties. — Single  or  unilateral,  and  bilateral  or  double  ;  upon 
the  same  side,  unilocular,  bilocular,  or  multilocular,  idiopathic, 
traumatic,  and  secondary,  e.  y.,  tuberculous,  or  cancerous.  Chronic 
pleurisy,  so  called,  is  merely  the  consequence  of  an  acute  attack. 

Symptoms  and  Course.— Generally,  after  a  chill  or  cold  stage, 
sharp  pain  in  the  side,  impeded  and  accelerated  respiration,  short, 
sharp  cough,  and  fever.  The  pain  centres  in  the  infra-manmiary 
or  lower  axillary  region  ;  it  is  often  intense,  and  is  increased  by  a 
long  breath,  by  coughing,  pressure,  or  lying  on  the  affected  side. 
Dr.  Peacock  asserts  ^  that  in  many  cases  the  patient  suffers  only 
discomfort,  with  little  pain  and  no  fever.  I  have  met  with  but  one 
or  two  such  instances,  in  which  it  may  be  a  question  whether  the 
term  pleuritis  or  that  of  liydrothorax  should  be  applied.  The  pain 
and  fever  lessen  after  efiusion  has  occurred  ;  but  the  dyspnoea  may 
then  be  increased.  It  is,  after  that  period,  most  comfortable  to  lie 
on  the  diseased  side,  so  as  to  allow  of  free  breathing  by  the  other 
lung.  Acute  pleurisy  is  often  recovered  from  without  any  con- 
siderable efiusion.  When  the  latter  does  occur,  absorption  mostly 
follows.  If  not,  life  is  endangered  by  interference  with  respiration. 
At  first  serous,  constituting  one  form  of  hydrothorax,  the  fluid 
may  become  purulent ;  this  is  pyothorax  or  empyema.  The  term 
false  empyema  is  given  to  a  collection  of  pus  in  the  pleural  cavity 
from  the  rupture  of  an  abscess  in  the  lung.  Pneumothorax  is  the 
accumulation  of  air  in  the  cavity  of  the  pleura  ;  hydro-pneumo- 
thorax,  of  water  and  air  together.  Both  of  these  are  most  com- 
mon in  tuberculous  pleurisy,  i.  e.,  occurring  in  the  course  of  a 
case  of  pulmonar}'  phthisis. 

Stages. — In  severe  pleuritis  there  may  be,  1,  the  adhesive  ;  2, 
the  effusive ;  3,  the  suppurative  stage.  In  favorable  cases  the 
third  stage  is  that  of  absorption. 

Physical  Signs. — Of  the  first  stage,  deficient  elevation  of  the  ribs 
in  breathing,  feeble  respiratory  murmur  on  the  affected  side,  and 
friction-sound.  Second  stage,  dulness  of  resonance  on  percussion, 
bronchial  respiration,  bronchophony,  sometimes  cego^yhony.  When 
the  effusion  becomes  very  copious,  bulging  of  the  side  occui'S,  with 
suppression  of  respiratory  sound  and  of  vocal  resonance  and 
vibration,  and  exaggerated  or  puerile  respiration  on  the  sound 
side.  Displacement  of  the  heart  may  take  place  if  the  effusion 
be  on  the  left  side  ;  of  the  liver  if  on  the  right.  There  is  no 
physical  sign  by  which  empyema  can  be  certainly  distinguished 
from  serous  effusion  ;  but  irritative  fever  usually  accompanies 
empyema. 

Baccelli,  of  Rome,  has  pointed  out^  that  the  thickness  and 
heterogeiieous  character  of  the  fluid  in  empyema  (presence  of 
pus  corpuscles,  etc.)  must  produce  greater  interruption  of  the 
conduction  of  sound  than  when  serous  fluid  only  is  present. 
This  is  observed  in  auscultation  of  vocal  sounds ;  which,  as  well 
as  bronchial  breathing,  are  (if  Baccelli  is  right)  not  to  be  heard  at 

1  British  Medical  Journal,  July  20,  1872. 

2  London  Med.  Record,  Aug.  15, 1876. 


202      DISEASES   OF   ORGANS  OF   RESPIRATION. 


the  base  of  a  purulent  effusion.  There  are,  however,  not  a  few 
cases  in  which  vocal  resonance  may  be  heard  (notwithstanding 
the  presence  of  effusion)  all  over  the  chest^^but  it  is  then  muffled 
over  the  effusion.  Above  the  seat  of  effusion,  where  the  lung  is 
condensed,  it  is  apt  to  be  louder  than  usual. 


Displacement  of  Heart  by  Pleuritic  Effusion. 

"When  the  amount  of  fluid  effused  is  not  very  great,  there  may 
be  observed  an  in  and  out  movement  at  the  intercostal  spaces,^ 
synchronous  with  the  respirations.  In  some  such  cases,  also,  of 
a  chronic  character,  even  before  retraction  from  absorption  has 
begun,  the  measurement  of  the  healthy  side  of  the  chest  may  be 
as  large  as,  or  occasionally  even  larger  than,  that  of  the  side  of 
the  effusion ;  yet  the  rounded  shape  of  that  side,  with  the  other 
physical  signs,  will  distinguish  it  upon  inspection. 

Absorption  following  extensive  effusion  induces  retraction  and 
depression  of  the  chest  on  that  side,  from  the  slow  or  imperfect 
expansion  of  the  lung.  Then  return,  first,  bronchial  respiration 
and  voice,  or  segophony  ;  afterwards,  gradually,  the  normal  respi- 
ratory murmur.  Sometimes,  from  adhesions  of  false  membrane 
over  the  lung,  permanent  depression  of  the  thorax  on  that  side 
is  left. 

During  effusion,  its  fluid  character  as  well  as  extent  may  be 
shown  by  percussion  in  different  positions.     Sitting  up,  it  falls 

1  Edinburgh  Med.  Journal,  October,  1880. 


PLEURISY.  203 

forward,  and  rises  to  a  higher  line  in  front ;  lying  on  the  back, 
the  dulness,  from  gravitation,  may  fall  much  lower  in  the 
anterior  region.  Sometimes  adhesions  prevent  this.  Succussion, 
or  sudden  shaking  of  the  chest  of  the  patient,  may  produce  an 
audible  splashing,  if  the  ear  'be  upon  or  near  the  affected  side. 
By  ocular  inspection  and  'measurement,  the  changes  in  the  amount 
of  the  effusion  may  be  estimated  from  time  to  time. 

Terminations. — Pleurisy  may  sometimes  be  "nipped  in  the 
bud "  at  an  early  stage  by  appropriate  treatment ;  that  is, 
prompt  resolution  of  the  incipient  inflammation  may  be  effected. 
The  other  terminations  are,  serous  effusion,  which  may  vary 
from  an  ounce  or  two  to  quarts,  gradually  absorbed  altogether; 
the  same,  slowly  and  incompletely  absorbed,  leaving  collapsed 
lung ;  death,  in  double  pleurisy,  by  asphyxia  from  excess  of 
fluid ;  and  empyema,  often,  but  not  nearly  always,  fatal  by  slow 
exhaustion. 

Complications. — Pneumonia,  tubercular  deposit,  inflammation 
of  the  liver  (bilious  pleurisy). 

Sequelae. — What  authors  call  chronic  pleurisy  is  the  sequela  of 
acute  pleuritis.  Its  results  and  terminations  have  been  above 
named. 

Morbid  Anatomy. — In  the  early  period,  general  redness  and 
vascular  injection  of  the  pleura,  with  bands  of  whitish  and  more 
or  less  translucent  or  opaque  coagulable  lymph,  causing  adhe- 
sions of  the  pulmonary  and  costal  pleura.  Later,  serous,  san- 
guinolent,  or  purulent  effusion,  in  variable  quantity  ;  sometimes 
displacement  of  the  heart,  lungs,  and  liver,  and  bulging  of  the 
ribs  and  intercostal  spaces. 

Diagnosis. — From  pneumonia,  pleurisy  is  known  in  the  height 
of  the  acute  attack,  by  the  sharpness  of  the  pain,  the  friction- 
sound,  and  absence  of  crepitant  r<\le  and  of  dulness  on  percussion. 
After  effusion,  especially  by  the  change  of  the  line  of  dulness  with 
change  of  position,  sitting  and  recumbent ;  by  the  bulging ;  and 
by  the  degree  of  diminution  of  vibration  of  the  walls  of  the  chest 
when  speaking. 

From  intercostal  neuralgia,  pleurisy  is  distinguished  by  the 
absence  of  fever  and  friction-sounds  in  the  former,  and  the  non- 
increase  of  the  neuralgic  pain  upon  inspiration.  Congestion,  in 
some  rare  cases,  attend.s  neuralgia ;  the  diagnosis  is  then  more 
diflicult.  In  intercostal  muscular  rheumatism,  there  is  slight 
increase  of  pain  in  breathing  deeply,  but  also  as  much  in  moving 
the  arms ;  the  pain  is  much  less  acute,  and  the  attack  is  gener- 
ally without  fever. 

Prognosis. — Pleurisy  is  rarely  fatal ;  though  death  may  occur, 
from  very  abundant  effusion  in  bilateral  j)leuritis,  or  with  empy- 
ema in  the  unilateral,  through  gradual  exhaustion. 

Causation. — Exposure  to  cold  and  damp  is  the  ordinary  excit- 
ing cause  of  "idiopathic"  pleurisy.  Fracture  of  the  rib,  punc- 
tured wounds,  etc.,  may  cause  traumatic  pleurisy.  In  the  course 
of  phthisis,  it  not  uncommonly  occurs  by  extension  of  disease 
from  the  lung.  Cancer  of  the  chest  may  produce  it  in  an  analo- 
gous manner. 

Treatment. — In  young  and  vigorous  persons  still  more  confl- 


204      DISEASES   OF   ORGANS   OF  RESPIRATION. 

dence  may  be  placed  in  early  antiphlogistic  treatment  than  in 
pneumonia.  When  high  fever  and  constant  severe  pain  occur, 
bleeding,  in  such  patients,  on  the  first,  second,  or  third  day, 
should  be  the  general  rule.  Leeches  or  cups  may  follow,  or  be 
used  instead  of  venesection  in  doubtful  cases.  Tartar  emetic, 
after  a  free  purge,  may  be  given,  ^  to  |  of  a  grain  every  two  or 
three  hours,  with  ^  to  1  grain  of  ojjium.  Some  practitioners  add 
calomel,  J  grain  to  1  or  2  grains  every  two  or  three  hours.  [F.  9.] 
I  believe  it  may  be  generally  omitted  without  risk.  When  fever 
subsides,  or  vomiting  occurs,  the  antimony  should  be  withdrawn; 
the  opium  and  perhaps  the  calomel  may  be  continued,  while  the 
pain  lasts — carefully  avoiding  over-narcotism  by  the  former  and 
salivation  by  the  latter. 

Dr.  Anstie  prefers  the  early  hypodermic  injection  of  acetate  of 
morphia ;  the  side  being  then  enveloped  in  a  hot  poultice.  Dr. 
F.  T.  Roberts^  advises  maintaining  the  affected  side  at  rest  by 
strapping  it  with  wide  strips  of  adhesive  plaste,r. 

As  soon  as  the  heat  of  skin  has  considerably  abated,  if  the  pain 
continues,  a  large  blister  should  be  applied  over  the  affected 
part. 

For  the  effusion^  diuretics,  as  squill  [F.  10],  juniper-berry  infu- 
sion, or  compound  spirit  of  juniper  [F.  11],  acetate  or  bitartrate 
of  potassium  [F.  12],  etc.,  may  be  used.  Iodine,  in  Lugol's  solu- 
tion, and  iodide  of  potassium  alone,  are  often  advised.  Anstie 
relied  more  on  tincture  of  chloride  of  iron.  Jaborandi  (in  drachm 
doses,  four  times  a  day)  has  been  used  with  success  by  Crequy^ 
and  Da  Costa.  Repeated  blistering  sometimes  has  excellent 
effect.  Purgatives  seem  to  be  much  less  successful  in  removing 
pleuritic  effusion  than  in  carrying  off  that  of  ascites,  or  anasarca. 
They  should  be  used,  if  at  all,  with  caution,  to  avoid  debilitation. 
Dr.  Sutton,  of  the  London  Hospital,  insists  on  the  importance, 
as  a  rule,  of  rest  in  bed. 

When  life  seems  to  be  threatened  or  the  general  health  much 
impaired  by  exhaustion  from  dyspnoea,  owing  to  large  effusion 
not  becoming  absorbed,  paracentesis,  or  puncture  of  the  chest,  is 
proper.  This  operation  is  now  much  more  frequently  performed, 
and  at  an  earlier  stage  of  pleurisy,  than  formerly.  Anstie's  rules 
(Reynolds'  System  of  Medicine,  article  Pleurisy)  for  concluding 
upon  it  are  these:  Paracentesis  should  be  performed  "1.  In  all 
cases  of  pleurisy,  at  whatever  date,  where  the  fluid  is  so  coj)ious  as 
to  fill  one  pleura,  and  begins  to  compress  the  lung  of  the  other 
side  ;  for  in  all  such  cases  there  is  the  possibility  of  sudden  and 
fatal  orthopnoea.  2.  In  all  cases  of  double  pleurisy,  when  the  total 
fluid  may  be  said  to  occupy  a  space  equal  to  half  the  dimensions 
of  the  two  pleural  cavities.  3.  In  all  cases  where,  the  effusion 
being  large,  there  have  been  one  or  more  fits  of  orthopnoea.  4. 
In  all  cases  where  the  contained  fluid  can  be  suspected  to  be  pus, 
an  exploratory  puncture  must  be  made ;  if  purulent,  the  fluid 
must  be  let  out.  5.  In  all  cases  where  a  pleuritic  effusion  occu- 
pying as  much  as  half  of  one  pleural  cavity  has  existed  as  long 
as  one  month,  and  shows  no  sign  of  progressive  absorption."    In 

1  Handbook  of  Theory  and  Practice  of  Medicine,  1873. 

2  Bulletin  Gen.  de  Therapeutique,  March  30,  1875. 


PLEURISY.  205 

the  history  of  thoracentesis  the  names  of  Trousseau  (1843),  Bow- 
ditch,  AUbutt,  and  Diculafoy  have  been  most  prominent.  Dr. 
Bowditch  has  most  frequently  used  Wyman's  apparatus,  which 
is  a  trocar,  with  a  silver  cannula,  having  a  stopcock,  and  capable 
of  being  connected  with  a  syringe  by  an  intermediate  piece,  also 
having  a  stopcock,  both  cocks  acting  the  same  way.  The  opera- 
tion is  performed  while  the  patient  is  sitting  up,  if  able,  or  lying 
over  the  edge  of  the  bed.  The  puncture  is  made  somewhere 
between  the  sixth  and  tenth  ribs  (Bryant  prefers  the  sixth  or^ 
seventh  intercostal  space ;  Laennec,  Stokes,  and  Walslie  have 
advocated  the  fifth),  just  behind  their  angles ;  making  sure  first 
of  the  position  of  the  liver  and  spleen,  so  as  to  avoid  them. 
Insert  the  instrument  (rather  quickly)  near  the  upper  edge  of 
the  lower  rib,  raising  its  point  as  it  goes  in.^  When  the  trocar  is 
witiidrawn,  the  fluid  may  be  gradually  removed  by  the  double- 
cocked  syringe  with  safety  to  the  slowly  expanding  lung.  The 
operation  may  need  to  be  repeated,  even  several  times  in  the 
same  patient.  The  occurrence  of  albuminous  expectoration  after 
thoracentesis  has  given  rise  to  considerable  debate  in  France.^ 

The  grooved  needle  or  exploring  trocar  (T.  Davies)  is  often, 
used  to  ascertain  the  nature  of  the  contents  of  the  chest.  Bla- 
chey,  of  Paris,  prefers  a  very  fine  "capillary"  trocar  for  the 
operation  of  thoracentesis.  Dieulafoy's  xmeumatic  aspirator  has 
attracted  much  attention.  It  does  appear  to  be  an  improve- 
ment upon  all  apparatus  so  far  employed  for  the  same  purpose  ; 
reducing  the  danger  of  puncturing  the  cavities  of  the  body  to  a 
minimimi.  Suction  should  be  stopped  as  soon  as  any  distressing 
or  very  uncomfortable  symptoms  (stricture,  violent  cough,  etc.) 
result.  Yibert^  recommends  the  preliminary  hypodermic  injec- 
tion of  morphia  to  prevent  pain  and  syncope.  When  pus  is  pres- 
ent (empyema,  pyothorax)  in  considerable  amount,  "drainage" 
may  be  resorted  to.  Following  the  grooved  needle  or  trocar,  a 
tine  long  iron  probe,  somewhat  bent,  is  passed  through  to  the 
lower  and  back  part  of  the  pleural  cavity,  against  the  intercostal 
space.  Being  felt  there,  an  incision  is  made  upon  it ;  a  strong 
silk  thread  is  passed  through  its  eye,  and  then  drawn  through 
the  first  opening.  After  this,  draw  in  a  drainage  tube  of  India- 
rubber  perforated  with  many  holes ;  both  of  whose  ends  hang 
out  and  are  to  be  tied  together.  Sometimes,  by  the  tube,  the 
cavity  may  be  washed  out,  with  water,  or  dilute  astringent  or 
antiseptic  solutions.  Dr.  Bowditch  latterly  has  expressed  a 
preference  for  a  free  incision  in  an  intercostal  space,  low  down  in 
the  back,  instead  of  tubular  drainage,  for  empyema.  Such  an 
opening  may  be  kept  open  with  lint,  as  long  as  may  be  needful. 

Eoser,  Konig,  and  Peltavy^  advise  (and  have  practised  with 
some  success)  resection  of  a  portion  of  a  rib  (usually  the  sixth) 
for  the  radical  cure  of  empyema.  One  advantage  claimed  for 
this  operation  is  that  it  does  away  with  the  necessity  for  a 
canula ;  so  that  the  pleura  is  saved  from  the  irritation  liable  to 
be  caused  by  its  presence.     Yet  practitioners  of  experience  with 

1  Dr.  Leale,  of  Kew  York,  uses  a  scalpel  and  male  catheter,  instead  of  the  trocar  and 
cannla.  -  Lo  Mouvement  iNTedicale,  1873. 

3  Journ.  de  Therapeut.,  Dec.  25, 1876.        ^  Boiiiuer  KJin.  WochoDschrift,  May  8,  1876. 

IS 


206      DISEASES   OF   OIlGAI>rS   OF   EESPIR ATION. 

paracentesis  are  by  no  means  all  agreed  upon  the  necessity  of 
such  an  exsection.  Washing  out  or  "spraying"  the  pleural 
cavity  in  cases  of  empyema,  with  dilute  solutions  of  carbolic 
acid,  iodine,  permanganate  of  potassium,  has  become  a  prom- 
inent point  in  its  treatment  with  several  practitioners  (Fraentzel, 
Morgan,^  Eerguson,  Lowe). 

In  chronic  cases  of  pleuritic  effusion  or  empyema,  the  strength 
of  the  patient  requires  usually  to  be  supported  by  good  diet,  and 
sometimes  by  tonics.  This,  in  empyema,  is  often  the  most 
important  part  of  the  treatment. 

ABSCESS  OF  THE  LUNG. 

In  rare  instances,  inflammation  of  the  lung,  active  or  latent, 
may  terminate  in  abscess.  Before  rupture,  dulness  on  percus- 
sion, bronchial  respiration,  and  dyspnoea  proportioned  to  the  size 
of  the  abscess,  are  present.  When  an  opening  occurs  allowing 
the  matter  to  escape  into  the  bronchial  tubes,  the  rather  sudden 
commencement  of  purulent  expectoration  should  attract  atten- 
tion. Then  the  physical  signs  of  a  cavity  are  discoverable  by 
percussion  and  auscultation ;  amphoric  or  tympanitic  resonance 
on  percussion,  cavernous  respiration,  metallic  tinkling,  etc.,  vary- 
ing with  circumstances.  As  is  the  case  with  pleuritic  empyema, 
pulmonary  abscess  may  communicate  externally  by  a  sponta- 
neous opening. 

The  principal  importance  of  abscess  of  the  lung  consists  in  the 
possibility  of  mistaking  it  for  phthisis.  The  points  of  difference 
will  be  alluded  to  in  connection  with  that  disease. 

PULMONAEY  GANGRENE. 

This  may  occur  in  pneumonia  from  extreme  violence  of  the 
inflammation,  or  from  a  depressed  state  of  the  system ;  also  from 
cancer  within  the  chest,  pysemia,  etc.  It  is  rare,  but  less  so  than 
circumscribed  abscess  of  the  lung.  Except  when  very  narrowly 
limited,  pulmonary  gangrene  is  always  fatal.  Its  signs  are, 
coarse,  mucous  rAle,  taking  the  place  of  the  vesicular  murmur  in 
the  lower  part  of  the  lung ;  with  copious  brownish  and  offensively 
fetid  expectoration,  dyspncea,  and  great  prostration. 

In  bronchitis,  occasionally,  temporary  fetor  of  the  expectora- 
tion and  breath  may  simulate  gangrene ;  but  transiently,  and 
without  the  above-mentioned  symptoms. 

The  treatment  of  pulmonary  gangrene  must  be,  of  course,  sup- 
porting and  antiseptic.  Alcoholic  stimulants,  rather  freely  given, 
will  be  proper,  with  concentrated  liquid  food,  as  beef-tea.  Sul- 
phite of  sodium  (ten  grains  in  solution  every  three  hours)  may 
be  tried ;  or  chlorine  water,  a  teaspoonful  or  two  every  two  or 
three  hours ;  or  carbolic  acid,  one  drop  in  solution  every  three  or 
four  hours. 

Inhalation  of  an  atomized  solution  or  emulsion  of  oil  of  eucalyp- 
tus is  recommended  for  its  antiseiDtic  effect. 

1  Lancet,  March  5,  1881. 


COLLAPSE    OP    THE     LUNG. 


207 


EMPHYSEMA  OF  THE  LUNG. 


Fig.  80. 


Vesicular  Emphysema. 


This  is  dilatation  of  the  pulmonary  air-cells  of  one  or  both  lungs. 
It  may  accompany  prolonged  asth- 
ma, or  may  follow  chronic  bron- 
chitis. Sometimes  it  aids  in  pro- 
ducing dilatation  of  the  heart. 
Its  symptoms  are  dyspnoea,  and 
when  extensive,  blueness  of  the 
lips,  cyanosis,  from  interference 
with  the  circulation  through  the 
lungs ;  in  many  cases  wheezing 
respiration. 

There  has  been  much  contro- 
versy as  to  whether  dilatation  of 
the  air-cells  is  produced  by  exces- 
sive distension  during  inspiration, 
or  by  obstruction  to  the  expiratory 
movement.  The  experiments  of 
Hutchinson  have  made  it  almost 
certain  that  the  latter  is  the 
general  rule ;  but  probably  both 
modes  of  explanation  may  apply 
to  different  cases. 

The  physical  signs  of  emphysema  are,  bulging  of  the  chest, 
increased  clearness  of  resonance  on  percussion,  and  feeble  inspi- 
ratory murmur  with  prolonged  expiratory  sound  ;  sometimes  dis- 
placement of  the  heart  or  liver.  It  is  most  easilj^  mistaken  for 
pneumothorax.  But,  in  the  latter^  the  resonance  on  percussion  is 
more  tympanitic,  the  inspiratory  murmur  still  feebler,  or  quite 
absent,  and  there  is  no  prolonged  expiratory  sound  ;  besides  which, 
the  concomitants  of  pneumothorax  usually  serve  to  distinguish  it. 

Pulmonary  hydatids  are  rare  and  difficult  of  diagnosis,  for  an 
account  of  which  the  student  may  be  referred  to  more  extended 
treatises.  Hydatids  of  the  lungs  are  said  to  be  not  uncommon 
in  Australia.  Dr.  L.  D.  Bird,^  of  Victoria,  claims  to  have  cured 
a  number  of  cases  by  tapping  the  cysts  (mostly  at  the  base  of 
the  lung),  and  then  administering  anti-parasitic  medicines ;  as 
bromide  or  iodide  of  potassium  and  kameela. 

COLLAPSF  OF  THE  LUNG. 

In  hooping-cough  or  in  severe  bronchitis,  especially  in  children, 
obstruction  of  a  considerable  air-tube  may  lead  to  an  exhaustion 
of  air  from  the  cells  supplied  by  it,  and  a  return  of  that  poi-tiou 
of  the  lung  to  the  unexpanded  condition  {atelectasis)  of  foital  life. 
The  same  state  may  occur  under  other  circumstances,  from  debil- 
ity. It  was  formerly  always  mistaken  for  lobular  pneumonia.  It 
is  usually  fatal,  unless  very  much  limited. 

Signs  of  it  (often  difficult  of  determination,  however)  are,  mod- 
erate dulness  on  percussion,  with  absence  of  the  murmur  of  respi- 
ration ;  and,  in  some  cases,  an  inward  motion  or  recession  of  the 
lower  ribs  during  the  effort  at  inspiration. 


I  London  Lancet,  July  1, 1871. 


208       DISEASES   OF   ORGANS    OF    E  ES  PI  R  AT  lOJST . 


BRONCHITIS. 

Definition. — Inflammation  of  the  mucous  membrane  of  the 
bronchial  tubes. 

Varieties. — Acute  and  chronic ;  general  and  capillary  ;  plastic, 
rheumatic,  and  syphilitic  bronchitis. 

Symptoms  and  Course. — Systemic  depression,  followed  by  fever; 
tightness  and  soreness  of  the  upper  and  anterior  part  of  the  chest ; 
cough,  at  first  short,  dry,  and  tight ;  later,  deeper  and  looser,  with 
expectoration  ;  the  latter  being  at  first  mucous,  in  rare  instances 
pseudo-membranous,  in  severe  cases  at  a  late  stage  purulent. 

Cainllary  bronchitis  is  marked  by  greater  dyspncea  and  tendency 
to  early  depression  and  prostration.  It  is  most  common  in  young 
children  and  in  the  aged  ;  and  is  considerably  more  dangerous 
than  ordinary  acute  bronchitis. 

Plastic  or  fibrinous  bronchitis  is  more  frequent  in  children  than 
in  adults,  but  is  comparatively  rare  (Lebert)  in  the  aged.  Dr. 
Glasgow,^  of  St.  Louis,  has  found  records  of  twenty-three  Ameri- 
can, and  more  than  a  hundred  European  cases  of  this  variety  of 
bronchitis.^  It  is  certainly  rare  ;  many  practitioners  of  long  and 
large  experience  having  never  seen  a  case.  It  is  recognized 
simply  by  the  expectoration  of  casts,  more  or  less  extensive,  of  the 
bronchial  tubes.  Most  generally,  it  occurs  in  the  chronic  form. 
If  the  fibrinous  exudation,  Avhen  formed,  cannot  be  thrown  off, 
the  patient  dies  of  dyspnoea.  In  a  number  of  instances,  however, 
attacks  of  the  same  kind  have  taken  place  repeatedly  for  years. 

Olironic  bronchitis  is  often  free  from  febrile  symptoms ;  the 
cough  and  expectoration,  with  slight  dyspnoea,  characterizing  it. 

Stages. — Ordinary  bronchitis  may  be  divided  in  its  progress 
into,  1st,  the  stage  of  diminviion  of  secretion ;  and  2d,  that  of 
increase  and  perversion  of  it. 

Physical  Signs. — ISo  dulness  on  percussion,  except  in  case  of 
collapse  of  part  of  a  lung  from  obstruction,  or  extensive  capillary 
bronchitis ;  sonorous  rhonchus  and  sibilus,  generally,  though  not 
quite  always,  on  both  sides  of  the  chest ;  varying  from  time  to 
time,  in  seat,  character,  and  loudness.  In  capillary  bronchitis, 
extended  mucous,  crepitant  or  subcrepitant  rMes,  closely  resem- 
bling the  fine  crepitation  of  pneumonia. 

Terminations. — Acute  bronchitis  may  end  in  death  from  apnoea, 
in  the  first  or  second  stage  ;  or  in  chronic  bronchitis  ;  but  most 
generally  in  recovery. 

Complications. — Asthma;  pneumonia;  bronchial  dilatation; 
pulmonary  collapse.  Broncho-pneumonia  is  especially  common  in 
early  life.  Disease  of  the  heart  (especially  of  the  left  side)  is,  not 
rarely,  attended  by  chronic  bronchitis,  as  well  as  by  attacks  of 
pulmonary  congestion. 

Morbid  Anatomy. — General  redness  and  congestive  tumefac- 
tion of  the  bronchial  membrane  ;  with  more  or  less  obstruction 
from  mucus  (in  chronic  cases  pus),  epithelium,  and,  rarely,  casts 
of  the  tubes  of  plastic  lymph. 

1  Transactions  of  American  Medical  Association,  1879. 

2  Reported  by  Peacock,  Eiegel,  Biermer,  Lebert,  and  others. 


BRONCHITIS.  209 

Diagnosis.— No  difficulty  exists  except  in  distinguishing  chronic 
bronchitis  from  phthisis.  Absence  of  dulness  on  percussion  and 
of  the  signs  of  excavation,  are  most  important ;  the  expectora- 
tion also  is  whiter  and  of  less  weight  in  bronchitis  ;  and  there  is 
no  distinct  hectic  fever.  The  temijerature  does  not  rise  to  so  high 
a  degree  in  chronic  bronchitis  as  in  tubercular  phthisis. 

Prognosis. — Acute  bronchitis  may  be  dangerous  in  old  persons 
and  young  children  ;  seldom  fatal  in  vigorous  middle  life.  The 
capillary  form  is  always  most  serious  ;  death  taking  place  some- 
times from  the  tenth  to  the  twelfth  day.  Acute  fibrinous  bron- 
chitis, according  to  Lebert,  has  a  mortality  of  one  in  four  or  five 
cases.  Chronic  bronchitis  is  not  often  fatal,  even  by  exhaustion  ; 
but  it  may  last  an  indefinite  time,  even  many  months. 

Causation. — Exposure  to  cold  is  the  most  frequent  cause.  In  cer- 
tain employments,  as  needle-grinding,  cotton-spinning,  etc.,  solid 
particles  inhaled  cause  bronchitis  by  meclianical  irritation.  Trans- 
ference of  rheumatism  occasionally  induces  it  in  the  rheumatic 
diathesis ;  and  it  is  one  of  the  possible  manifestations  of  tertiary 
syphilis.  The  gouty  element,  also,  may  in  exceptional  instances 
be  recognized  in  its  production. 

Treatment. — Abortive  treatment  of  a  "cold  on  the  chest "  may 
sometimes  be  effected  within  the  first  twenty-four  hours,  by  taking, 
at  bedtime,  a  glass  of  hot  lemonade,  six  grains  of  quinine,  or  ten 
grains  of  Dover's  powder,  after  a  warm  mustard  foot-bath.  Should 
this  treatment  fail  or  be  omitted,  a  brisk  saline  purgative  should 
be  given,  of  Epsom  or  Eochelle  salts,  or  citrate  of  magnesium. 
Then,  when  the  fever  is  high,  cough  very  tight,  and  breast  sore, 
tartar  emetic  may  be  advised,  I  to  i  grain  every  two  or  three 
hours  [F.  1],  with  frequent  draughts  of  flaxseed  tea  or  some 
similar  demulcent ;  in  some  cases,  leeches  or  cut  cups  to  the 
upper  part  of  the  chest.  A  large  sinapism  over  the  upper  sternal 
region  will  aid  in  giving  relief;  and  so  will  friction  with  oil  of 
turpentine. 

In  milder  cases,  or  where  the  strength  of  the  stomach  is  doubt- 
ful, syrup  of  ipecacuanha,  \  to  \  drachm  every  two  or  three  hours, 
will  answer ;  and  it  should  be  continued  until  the  cough  softens 
and  the  breathing  becomes  easier.  Then  syrup  of  squills  [or,  F. 
13]  may  follow  in  fluidrachm  doses,  every  three  or  four  hours. 
Another  excellent  mild  expectorant  and  palliative  of  bronchial 
cough  is  syrup  of  wild  cherry  bark^  in  teaspoonful  doses.  When 
the  cough  is  troublesome  at  night,  I  to  1  fluidrachm  of  paregoric 
[F.  1.5]  may  be  added  at  bedtime ;  or  through  the  day,  occasion- 
ally, if  coughing  be  very  violent  or  frequent.  Opiates  do  the 
most  good,  however,  after  loosening  of  the  cough  with  free  expec- 
toration. When  the  fever  has  abated,  and  especially  if  dyspnoea 
continue,  a  blister  may  be  applied  over  the  sternum. 

In  capillary  bronchitis,  or  in  the  ordinary  form  in  the  aged  and 
feeble,  instead  of  tartar  emetic,  the  more  stimulating  expecto- 
rants may  be  required,  as  senega,  in  decoction  or  syrup,  chloride 
[F.  15]  or  carbonate  of  ammonium,  with  quinine  and  beef-tea, 
wine-whey,  or  whisky  punch.  Inhalation  of  .steam,  alone,  or 
from  infusion  of  hops,  sometimes  soothes  the  air-tubes  advan- 
tageously. 

18*  O 


210      DISEASES  OF   OEGANS   OF   RESPIEATION, 

Dr.  Bedford  Brown,'  of  Virginia,  in  a  number  of  cases  in  chil- 
dren, has  found  tlie  early  use  of  an  emetic  of  ipecacuanha  very 
serviceable  ;  a  combination  of  ipecac  and  quinine  being  continued 
afterwards.  Korrmann  recommends  muriate  of  apomorphia  as 
an  expectorant ;  3^,5  gr.  for  a  child  three  years  old.  This  is  a 
rather  large  dose.  Beck  (Lond.  Med.  Record,  April  15,  1881) 
advises  ^^5  grain  doses  of  the  same  medicine  for  a  child  under  ten 
years  of  age.  In  children,  especially,  warm  poultices^  as  of  mush 
and  mustard,  over  the  chest,  are  beneficial. 

Chronic  bronchitis  requires  persevering  use  of  counter-irrita- 
tion over  the  chest,  by  croton  oil  (3  drops  with  as  much  of  sweet 
oil  applied  nightly  till  a  papular  eruption  follows),  painting  with 
tincture  of  iodine,  or  plasters  of  Burgundy  pitch,  hemlock,  etc., 
and  alternation  of  stimulating  and  alterative  expectorants,  and 
tonics.  Besides  squill  and  senega,  ammoniacum,  copaiba  [P.  17] , 
and  chloride  of  ammonium  [F.  16]  are  most  frequently  useful. 
Eucalyptol  (dose,  about  0  minims)  is  an  expectorant  of  consider- 
able i)ower.  Grindelia  rohusta^  of  California,  has  lately  acquired 
a  similar  reputation.    Dose  of  fluid  extract,  half  a  fluidrachm. 

Dr.  T.  Clark  (Practitioner,  April,  1878),  has  reported  good 
effects  in  chronic  congh  from,  oxalate  of  cerium;  five  grains  each 
morning,  before  rising.  Others  have  preferred  employing  it  in 
smaller  doses,  morning  and  night.  It  appears  to  act  as  a  calma- 
tive, without  disordering  the  stomach.'^ 

Dr.  Lander  Brunton  asserts  that  carbonate  of  potassium  tends 
to  render  bronchial  expectoration  fluid  and  abundant ;  while 
nitric  acid  has  the  ojiposite  effect,  of  diminishing  its  amount. 
These  opposed  indications  may  both  occur  at  different  periods  in 
the  same  case.  If  the  system  be  below  par,  quinine,  iron,  and 
cod-liver  oil  are  important.  "When  secretion  is  very  copious, 
inhalation  of  tar-vapor  or  of  creasote  should  be  tried.  The 
former  may  be  used  by  putting  an  ounce  or  two  of  tar  in  a  cup 
over  boiling  water ;  so  as  to  diffuse  the  tar  vapor  through  the 
chamber.  Creasote,  20  or  30  drops,  may  be  put  into  half  a  pint 
of  boiling  water,  to  be  breathed  from  by  means  of  an  ordinary 
inhaler.  Dr.  J.  A,  LidelF  uses  by  preference  the  atomizer,  with 
a  solution  of  one  grain  of  carbolic  acid  in  an  ounce  of  water. 
"When  medicine  fails,  change  of  air  will  sometimes  entirely  cure. 

Dr.  Gi-reenhow*  has  pointed  out  that  patients  with  chronic 
bronchitis  generally  do  better  when  mucli  out  of  doors,  than 
when  confined  closely  to  the  house. 

On  Haemoptysis,  see  Semeioloyy ;  also  the  article  on  Phthisis, 
and  that  on  Memorrhayes. 

ASTHMA. 

Definition. — Paroxysmal  and  spasmodic  dyspnoea. 
Varieties. — Idiopathic  a,nd  symptomatic;  cZ^/sj3epf^■c  asthma ;  hay 
asthma. 
Symptoms  and  Course.— Every  night,  or  once  a  week,  month, 

1  Am.  Journal  of  Med.  Sciences,  October,  1870. 

2  H.  Cheeseman,  N.  Y.  Med.  Becord,  June  12,  ISSO,  p.  G64. 
2  N.  Y.  Medical  Record,  July  1,  1872. 

*  0»  Chronic  Bronchitis,  etc.  London,  1869. 


ASTHMA.  211 

or  year,  or  at  irregular  intervals,  the  attack  comes  on.  Most  fre- 
quently it  is  iK'twcen  one  and  three  o'clock  in  the  morning.  Pre- 
monitory symptoms  often  are  gn^at  drowsiness,  or  wakefulness, 
headache,  flatulence,  itchins*  under  the  chin,  Dyspniwa  then 
l)ecomes  the  charact(^ristic  symptom.  The  sufferer  sits  or  stands 
up,  leaning  forward,  and  labors  to  breathe.  The  chest  is  expanded 
to  its  utmost,  by  the  accessory  as  well  as  principal  inspiratory 
muscles.  The  countenance  is  anxious,  with  pallor,  coldness,  and, 
in  severe  cases,  lividness  of  the  face  and  hands.  Perspiration 
is  often  copious,  A  wheezing  sound  accompanies  respiration ; 
giving  way  finally,  with  relief,  upon  the  expectoration  of  mucus, 
usually  rather  thick,  and  in  pellets. 

The  attack  may  pass  over  in  a  few  minutes,  or  may  last  for 
hours ;  or,  with  some  remission,  days  or  weeks.  Where  asth- 
matic symptoms  are  persistent^  as  is  not  very  uncommon,  for 
years,  some  structural  change  in  the  organs  of  the  chest  must 
exist ;  it  is  then  symptomatic  asthma. 

Physical  Signs. — Inspection  shows  unusual  elevation  of  the 
ribs  and  shoulders.  Placing  the  ear  on  the  chest,  sonorous  and 
sibilant  sounds,  loud  but  mostly  small  in  calibre,  are  found  to 
take  the  place  of  the  respiratory  murmur.  These  sounds  change 
their  locality  frequently  ;  and  they  are  usually  douhle;  i.  e,,  occur 
both  with  inspiration  and  with  expiration.  As  the  attack  gives 
way  with  expectoration,  the  mucous  rale  is  heard. 

Secretions. — At  the  beginning  of  the  paroxysm,  the  urine  is 
abundant  and  pellucid  ("nervous  urine") ;  for  some  hours  after 
the  attack  has  ceased,  it  is  more  scanty,  and  deficient  in  urea 
and  chloride  of  sodium. 

Complications. — Bronchitis ;  puhnonary  emphysema ;  dilata- 
tion or  hypertrophy  of  the  heart. 

Diagnosis. — Laryngeal  spasm  may, without  care,  be  confounded 
with  asthma ;  but  the  modification  or  arrest  of  the  voice  ought  to 
distinguish  the  former.  Violent  bronchitis  is  known  from  it  by 
the  febrile  condition.  Angina  pectoris,  by  the  extreme  pain, 
and  localization  of  distress  about  the  heart,  Hydrothorax,  by 
the  dulness  of  resonance  on  percussion,  and  absence  of  rhonchus. 
Special  exploration  is  necessary  in  each  case  to  determine  the 
presence  or  absence  of  pulmonary  or  cardiac  complication. 

Prognosis. — Death  almost  never  occurs  during  the  fit  of  asthma. 
Those  subject  to  it  often  live  to  old  age.  But  dilatation  of  the 
pulmonary  air-cells,  and  enlargement  of  the  heart,  may  follow  in 
protracted  cases,  breaking  down  the  health. 

Pathology  and  Nature. — It  has  been  made  almost  certain  that 
asthmatic  dyspnoea  is  owing  to  a  spasmodic  constriction  of  the 
smaller  bronchial  tubes,  by  tonic  contraction,  mostly  reflex,  of 
their  involuntary  muscular  fibres.  Perhaps  the  intercostal 
muscles  and  diaphragm  may  be  sometimes  involved,  Savignac^ 
considers  jjaraZ7/si6'  (how  paroxysmal?)  of  the  bronchial  muscular 
fibres  more  probable  than  their  spasmodic  contraction.  This 
view  is  not  likely  to  receive  much  support. 

Causation. — Asthma  is  hereditary  in  a  majority  of  cases.   Males 

1  Bulletin  Gonyral  de  TlijrapL'utique,  Nuv.  30,  1867. 


212      DISEASES  OF  ORGANS  OP  RESPIRATION. 

have  it  more  often  than  females.  It  may  occur  at  any  age.  Dr. 
Salter  classifies  cases  according  to  their  causation — 1,  by  agencies 
acting  upon  the  lungs,  as  fog,  smoke,  fumes  of  various  things, 
ipecacuanha,  mustard,  new  hay,  etc. ;  2,  by  reflex  action,  as  irri- 
tation of  the  stomach  from  indigestion,  loaded  rectum,  sudden 
emotion ;  3,  by  pulmonary  or  cardiac  disease.  Behind  aU  these 
there  must  be  a  predisposing  peculiarity  of  constitution. 

Treatment. — During  the  attack,  our  aim  is  to  give  relief,  by 
relaxing  spasm.  Ipecacuanha  wine,  with  tincture  of  lobelia,  one- 
quarter  to  one-half  fluidrachm  of  each  [F.  18] ,  every  half  hour 
until  nausea  or  expectoration  is  produced,  I  have  known  often  to 
act  very  well.  Hoffman's  anodyne,  in  one-half  drachm  or  drachm 
doses,  will  sometimes  do  great  good.  Some  practitioners  advise 
hyoscyamus,  musk  [F.  19],  hydrate  of  chloral,  or  hydrocyanic 
acid  [F.  20].  Smoking  tobacco  relieves  in  some  instances ;  smok- 
ing cigarettes  of  stramonium-leaves  in  others.  More  still  find 
comfort  in  breathing  the  air  in  which  are  burned  papers  which 
have  been  soaked  in  a  saturated  solution  of  nitrate  of  potassium. 
Inhalation  of  oxygen  has  been  found  beneficial  by  Demarquay, 
Andrew  H.  Smith,  and  others;  and  so  has  the  respiration  of 
compressed  air.  Inhalation  of  ether,  nitrous  oxide,  or  nitrite  of 
amyl  (three  to  five  drops),  may  be  carefully  used  in  extreme 
cases.  Hypodermic  injection  of  morphia  (Hirtz,  Huchard)  has 
sometimes  given  immediate  relief.  Dr.  T.  M.  Eochester  reports 
well  of  half-drachm  doses  of  fluid  extract  of  grindelia  rohusta. 
Tincture  of  quebracho^  in  teaspoonful  doses,  is  recommended  dur- 
ing the  attack,  by  Berthold  and  others.  As  an  adjuvant,  the 
warm  mustard  foot-bath  may  be  employed ;  as  well  as  sinapisms 
or  dry  cupping  between  the  shoulders. 

Between  the  attacks,  endeavor  should  be  made  to  rectify  diges- 
tion and  its  tributary  processes,  and  to  invigorate  the  nervous 
system.  Some  cases  will  require  blue  pill,  nitro-muriatic  acid 
[F.  21],  chloride  of  ammonium  or  taraxacum,  bitter  tonics  and 
mild  laxatives,  such  as  rhubarb,  etc.  Others  need  iron  and  qui- 
nine. Iodide  of  potassium  is  highly  recommended  by  some; 
conium,  cannabis  indica,  and  arsenic  in  small  doses  by  others. 
There  is  reason  for  giving  trial  to  the  bromide  of  potassium  in 
obstinate  cases ;  most  patients  will  bear  from  ten  to  twenty  grains 
of  this  twice  or  thrice  daily  for  weeks  together  without  inconven- 
ience [F.  22].  Dr.  Faulkner,  of  Allegheny  City,  Pa.,  has  found 
remarkably  beneficial  results  in  asthma  from  painting  with  iodine 
(tincture)  the  tracks  of  the  pneumogastric  nerves  in  the  neck ; 
from  the  thyroid  cartilage  to  the  upper  borders  of  the  clavicles. 
Dr.  Eobson  (British  Medical  Journal,  April,  1880)  has  used  with 
advantage  nitro-glycerin;  from  one  to  three  minims  of  a  one  per 
cent,  solution  at  a  dose.  Pilocarpine  hypodermically,  succeeded 
well  with  Berkart  (British  Medical  Journal,  1880,  Yol.  I.,  p.  960). 
Schajfi'er,  of  Bremen,  has  used  with  encouraging  success  the  appli- 
cation of  the  induced  electrical  current  to  the  throat  (across  the 
larynx  and  soft  palate).  A  current  is  employed  of  sufficient 
strength  to  be  decidedly  felt  by  the  patient.  Dr.  Yeo^  reports  a 
case  in  which  this  treatment  answered  very  well. 

1  Lancet,  November  13, 1880. 


ASTHMA.  213 

Prophylaxis. — Ko  disease  is  more  curiously  capricious  in  its 
causation  tlian  asthma.  Some  always  have  a  paroxysm  if  they 
visit  the  sea-sliore  ;  others  are  more  secure  there  than  elsewhere. 
One  cannot  sleep  on  the  first  floor ;  another  does  better  there  than 
higher  up.  Each  must  learn  his  own  peculiarities  and  be  gov- 
erned thereby. 

Dr.  Whitehead,  of  Denver,  insists, ^after  large  experience,  that 
the  climate  of  Colorado  has  a  remarkable  influence  in  promoting 
the  amelioration  and  cure  of  asthma. 

Most  remarkable  are  the  annual  attacks  of  asthma,  hay  fever, 
summer^  catarrh,  autumnal  catarrh,  or  asthmatic  bronchitis,  to 
which  some  individuals  are  subject.  The  symptoms  are  those  of 
a  violent  cold,  coming  on  generally  either  in  June  or  in  August. 
There  are  many  persons  who  for  years  are  obliged  to  arrange  all 
their  business  for  such  an  attack,  which  is  punctual  almost  to  a 
day.  Some  escape  the  paroxysm  only  by  going  to  the  sea-shore, 
and  others  to  the  mountains,  before  the  expected  time,  and 
remaining  there  through  the  time  during  which  it  would  have 
lasted.  Dr.  Sebastian,  of  Texas,  mentions  the  case  of  a  gentle- 
man who  was  enabled  to  escape  his  attacks  by  wearing  a  thick 
veil  through  the  period  of  their  expected  return. 

This  periodical  aftection,  however,  is  not  incompatible  with 
long  life  ;  several  of  its  victims  have  been  known  to  survive  their 
eightieth  year;  and  one,  at  least,  lived  to  be  ninety-five. 

In  a  number  of  cases,  the  application  to  the  nostrils  of  a  sat- 
urated solution  of  sulphate  of  quinine  has  arrested  the  paroxj^sm 
in  a  day  or  two,  several  different  years.  Prof.  Helmholtz,  of 
Berlin,  having  been  subject  to  "hay-fever,"  ascertained  in  1868 
that  the  secretion  from  his  nostrils  during  the  attacks  contained 
a  number  of  minute  yibrio-like  bodies,  absent  at  other  times. 
In  view  of  the  action  of  quinine  in  destroying  infusoria,  he 
applied  a  solution  of  it  to  his  nostrils,  with  excellent  effect.  Drs. 
Frickhofer  and  Busch  have  obtained  like  results.  (See  a  letter 
from  Prof,  Binz,  of  Bonn,  to  Prof.  Tyndall,  in  Nature,  May  14, 
1874.)  Dr.  E.  C.  Seguin  advises  frequent  use  of  a  strong  gargle 
of  bromide  of  amynonium  (5j  or  5ij  iii  fSJ  water)  and  a  solu- 
tion one-fourth  as  strong  as  a  wash  for  the  nostrils.  Dr.  Fer- 
rier's^  treatment  for  common  nasal  catarrh  is  worth  trying 
in  this  affection  also,  viz.,  by  snuffing  into  the  nostrils  powder 
of  suhnitrate  of  bismuth,  mixed  with  a  httle  morphia  and  gum 
arabic. 

Dr.  W.  Moss,  of  Philadelphia,  in  his  own  case  and  in  others, 
has  found  the  hypodermic  injection  of  morphia  to  give  great  relief. 
Dr.  Hoover,  of  Ohio,  shortened  the  duration  of  two  cases  by  atomi- 
zation  with  solutions  of  chlorate  or  bromide  of  potassium  with 
morphia.  Prevention,  however,  is,  in  the  case  of  periodical  ca- 
tarrh, emphatically  more  attainable,  as  well  as  better  than  cure. 
As  to  localities  almost  certainly  places  of  escape  for  those  subject 


1  American  Journal  of  Medical  Sciences,  April,  1874. 

2  See  Experimental  Researches,  etc.,  by  C.  H.  Blackley,  M.  R.  C.  S.,  London,  1873. 
Blackley  believes  pollen  to  be  the  usual  exciting  cause  of  this  alfection. 

8  Philadelphia  Medical  Times,  May  13,  1«7C. 


214      DISEASES    OF   ORGANS   OF    RESPIRATION. 


to  it,  the  following  is  the  report  of  Dr.  Morrill  Wyman,  after  care- 
ful investigation : 

"Long  and  varied  experience  with  numerous  individuals  has 
proved  that  (in  New  Hampshire)  the  Glen,  Gorham,  Randolph, 
Jefferson,  Whitefleld,  Bethlehem  village,  the  White  Mountain 
Notch,  Twin  Mountain  House,  the  high  level  about  Franconia 
Notch,  are  all  within  the  limits  of  safety.  Other  elevated  tracts 
are  safe :  Mount  Mansfield  at  Stowe,  Vermont,  and  the  Adiron- 
dacks  are  particularly  safe,  also  the  Ohio  and  Pennsylvania 
plateau,  including  the  high  range  of  southern  counties  in  New 
York,  from  the  Catskill  Mountains  to  the  western  border  of  the 
state ;  the  plateau  in  these  counties  having  an  elevation  of  two 
thousand  feet  above  the  sea.  The  valleys  of  the  rivers  and  lakes 
of  the  same  state,  at  a  lower  level,  are  not  safe.  The  Island  of 
Mackinaw,  and  the  country  north  of  the  great  lakes  in  Canada, 
and  beyond  the  Mississippi,  at  St.  Paul,  Minnesota,  have  a 
certain  immunity,  but  not  equal  to  that  of  the  Lake  Superior 
region.  Farther  west  are  large  tracts  which  may  be  resorted  to. 
South,  the  Allegheny  Mountains  at  Oakland,  and  other  elevated 
points,  and  Iron  Mountain,  on  the  Tennessee  and  North  Caro- 
lina line,  are  unusually  free.  To  the  east,  the  elevated  interior 
of  Maine  and  its  extensive  lakes  afford  both  pleasure  and  safety. 
Mount  Desert  is  not  free,  but  some  of  the  islands  about  it  are 
thought  to  give  relief  If  the  sea  coast  is  preferred,  the  whole 
coast  east  of  the  St.  John,  thence  quite  around  to  Labrador,  is 
open  to  the  subjects  of  autumnal  catarrh.  Sufferers  who  actually 
pitch  their  tents  in  these  favored  regions,  as  a  general  rule,  not 
only  escape  their  enemy,  but  may  find  themselves  at  the  end 
of  the  month  with  a  vigor  that  nothing  but  living  under  canvas 

seems  to  give. 
Fig.  81.  "The  limits  of  the  exempt 

regions  are  often  narrow  and 
very  sharply  defined." 

In  asthmatic  persons  gener- 
ally, nothing  is  more  impor- 
tant than  prudence  and  regu- 
larity in  diet  and  regimen. 


BRONCHIAL   DILATATION. 

This  (synonym,  bronchiec- 
tasis), of  which  extreme  de- 
grees are  not  common,  is  of 
interest  chiefly  because  it  is 
possible  for  it  to  be  mistaken 
for  phthisis.  There  are  two 
forms,  the  tubular  and  the  sac- 
cular enlargement. 

In  either,  slight  dulness  on 
percussion  may  occur  from 
condensation  of  the  lung  around  the  expanded  part.  Sonorous 
rhonchus  and  coarse  mucous  r^le  exist,  the  latter  especially  in 
the  saccular  form.  In  this,  the  signs  are  almost  identical  with 
those  of  tubercular  excavation ;  but  they  occur  usually  at  the 


Dilated  Bronchi. 


CHRONIC    NASAL    CATARRH,  215 

middle  or  lower  part  of  the  lung,  and  are  stationary,  as  they 
are  not  in  tuberculization. 

Dr.  Gairdner  describes  the  formation  of  ulcerative  excavations 
of  the  lung  communicating  with  the  inflamed  bronchi  as  "bron- 
chial abscess." 

Cough,  very  troublesome,  and  attended  by  copious  mucous  or 
slightly  purulent  expectoration,  is  common  in  bronchial  dilatation. 
The  palliation  of  this  symptom,  with  care  of  the  general  condition 
of  the  patient,  is  all  that  can  be  accomplished  for  it  in  treatment. 

CHEONIC  NASAL  CATARRH. 

This  often  troublesome  affection  is  sometimes  called  naso-pha- 
ryngeal  or  post-nasal  catarrh ;  or,  when  attended  by  obstruction 
of  the  nostrils,  oiasal  stenosis;  in  cases  of  offensive  discharge  or 
odor,  ozoena. 

It  is  most  common  in  children  ;  not  rarely  in  those  of  seem- 
ingly healthy  constitution,  but  Avorst  and  most  obstinate  gener- 
ally in  those  of  scrofulous  habit,  or  who  inherit  syphilis. 

Mild  cases  exhibit  merely  an  annoying  constancy  or  frequency 
of  mucous  discharge,  and  more  or  less  interference  with  nasal 
breathing.  In  others,  however,  there  is  painful  irritation  and 
copious  discharge ;  or  there  may  be  obstruction  of  one  or  both 
nostrils,  almost  absolute,  with  a  dry  state  of  the  swollen  Schnei- 
derian  membrane,  and  an  accumulation  of  thickened  mucus  in 
the  posterior  nares ;  which  becomes  offensive  from  putrefactive 
decomposition.  The  respiratory  portion  of  the  lining  membrane 
of  the  nostrils,  compared  (Kohlrausch,  Kolliker,  Bigelow)  to  the 
erectile  structure  of  the  penis,^  may  undergo  hypertrophy  to  such 
a  degree  as  to  be  sometimes  mistaken  for  polypus.  It  always 
differs  from  the  latter,  however,  in  the  absence  of  a  stem,  and  in 
the  immobility  of  its  mass. 

Worse  yet,  is  the  occasional  extension  of  inflammation  from 
the  mucous  membrane  to  the  bones  of  the  nose  ;  which  may  then 
sufier  destructive  caries.  Sometimes  (especially  in  syphilitic 
cases)  this  disorder,  ending  in  necrosis,  begins  in  the  turbinated 
or  other  osseous  structures. 

Ulceration  of  the  lining  membrane  of  tlie  nose  is  not  common, 
except  in  patients  of  syphilitic  constitution.  I  have  seen  it, 
however,  largely  affecting  the  septum,  in  a  case  in  which  such  a 
taint  was  quite  impossible. 

JSTot  unfrequently  the  antrum  maxillare,  on  either  side,  or  one 
or  both  of  ih.Q  frontal  sinuses^  may  be  involved.  In  the  last  case, 
dull  aching  pain  over  the  brow  may  be  experienced.  It  is  in  the 
instances  of  extension  to  the  maxillary  and  frontal  cavities  that 
the  fetid  discharge  called  ozoena  is  most  apt  to  be  met  with.  Not 
uncommonly,  in  such  cases,  no  nasal  discharge  occurs  ;  whatever 
is  secreted  passes  down  into  the  pharynx  ;  bxit  the  odor  may  still 
be  extremely  unpleasant  to  the  sufferer  and  to  others. 

Predisposition  to  nasal  obstruction  appears  to  have,  in  some 

1  Koe;  N.  Y.  Med.  Record,  AprU  30, 1881,  p.  486. 


216      DISEASES   OF   ORGANS   OF   RESPIRATION. 

persons,  an  anatomical  origin ;  in  a  symmetrical  growth  of  tlie 
bony  structure  of  the  nasal  cavities.^  Usually,  however  (apart 
from  strumous  or  syphilitic  constitutions),  chronic  nasal  catarrh 
is  the  result  of  repeated  or  prolonged  exposure  to  changes  of 
temperature,  and  especially  cold  and  damp,  such  as  abound  in 
our  American  climate. 

Effects  of  this  disorder,  besides  its  direct  annoyances,  may 
involve  loss  of  the  sense  ot  smell;  impairment  o{  hearing  (through 
extension  to  the  Eustachian  tube  and  middle  ear) ;  injurious 
modification  of  the  voice;  and  the  disadvantage  of  being  obliged 
to  breathe  through  the  mouth.  From  the  last  named  necessity, 
irritation  and  chronic  troubles  in  the  pharynx,  larynx,  or  even 
lungs  may  result. 

Treatment. — First,  we  must  ascertain  the  cause  and  nature  of 
the  affection.  Is  it  simply  idiopathic,  or  scrofulous,  or  syphilitic? 
Moreover,  surgeons  have  often  relieved  ozsena  by  the  removal  of 
foreign  bodies  from  the  nasal  cavities.  Careful  inspection  of  the 
nose  must  be  made,  by  aid  of  a  small  bivalve  speculum  and  the 
rhinoscopic  mirror.  (See  Rhinoscopy^  under  Semeiology,  in  Part 
I. )  But  it  is  of  great  consequence,  also,  to  have  full  information 
in  regard  to  the  constitutional  history  of  the  patient.  Should 
there  be  any  reasonable  suspicion  of  syphilis,  iodide  of  mercury 
ought  to  be  advised,  followed  by  iodide  of  potassium.  Either 
of  these  alteratives  may  be  given  along  with  syrup  or  pills  of 
iodide  of  iron.  For  the  scrofulous  diathesis,  Lugol's  solution, 
iodide  of  iron,  iodoform,  and  cod-liver  oil  may  be  prescribed,  suc- 
ceeding each  other  so  as  to  impress  the  system  through  a  long 
periodr  Plenty  of  time  is  apt  to  be  allowed  in  the  treatment  of 
chronic  nasal  catarrh ;  which  is  often  one  of  the  opjprobria  of 
medicine  as  well  as  of  surgery. 

Local  treatment,  however,  must  not  be  neglected.  It  has 
become,  of  late,  almost  a  special  surgical  department.^  The 
most  general  indication  is  cleansing,  and  when  ozsena  is  present, 
deodorization  and  disinfection  of  the  nasal  cavities.  For  this, 
syringing  is  less  effective  than  Weber's  and  Thudichum's  nasal 
douche.  This  consists  of  a  reservoir  containing  the  selected 
fluid,  to  be  held  a  little  higher  than  the  patient's  head ;  from 
it  depends  a  quarter-inch-bore  rubber  tube,  at  the  lower  end  of 
which  is  a  nozzle,  large  enough  to  fill  the  orifice  of  the  nostril. 
When  the  douche  is  administered,  the  ]Datient  must  breathe 
altogether  by  the  mouth,  and  avoid  swallowing.  Then  the  fluid 
will  enter  by  one  nostril  and  pass  out  by  the  other.  A  simple 
funnel,  or  a  bowl  or  pitcher  with  a  siphon,  will  answer  for  the 
reservoir.  The  movement  of  the  liquid  may  be  controlled  by 
raising  or  lowering  the  reservoir,  and  by  compressing  the  lower 
part  of  the  tube  between  the  thumb  and  fingers. 

For  simple  cleansing,  a  solution  of  common  salt  in  warm  water 
(a  teaspoonful  in  a  pint)  will  be  very  suitable.  Other  lotions  are 
employed,  containing  some  of  the  following  substances :  alum, 
borax,  boracic  acid,  chloride  of  ammonium,  compound  tincture 

1  Harrison  Allen ;  Phila.  Med.  Times,  Dec.  6,  1879,  p.  120. 

2  See  Bosworth,  on  the  "Throat  and  Nose;"  Beverley  Robinson,  "Chronic  Nasal 
Catarrh,"  etc. 


LARYNGITIS, 


217 


of  benzoin,  chlorate  of  potassium,  nitrate  of  silver,  sulphate  of 
zinc,  corrosive  sublimate,  tar-water,  permanganate  of  potassium, 
chlorinated  soda,  hydrate  pf  chloral,  iodoform,  carbolic  acid, 
salicylic  acid,  glycerin,  etc. 

Anoth(u-  mode  of  local  medication  of  the  nostrils  is  by  atomiza- 
tion  (see  Part  I.)  with  similar  solutions.  The  hand-hall  atomizer 
will  suffice  for  the  purpose.  Many  practitioners  prefer  insuffla- 
tion of  powders;  e.  {/.,  tannic  acid,  bismuth,  cubebs,  or  iodoform. 
Woakcs'  and  others  use  medicated  pellets  of  cotton-wool,  satur- 
ated with  the  preferred  agent  in  solution  with  glycerin.  [F.  340, 
341,  34-2,  343,  344,  345.] 

Latterly,  obstinate  cases,  in  which  hypertrophy  of  the  mucous 
membrane  over  the  lower  turbinated  bone  obstructs  the  nostril, 
destructive  local  treatment  is  much  in  vogue.  Escharotics  may 
be  used  for  this;  as  nitric,  chromic,  ov  glacial  acetic  acid.  The 
last  named  is  probably  the  best  for  the  purpose.  When  such 
applications  have  proved  insufficient,  removal  of  a  portion  of  the 
obstructive  mass  may  b^;  perfornied  by  means  of  a  snare-ecraseur, 
in  principle  like  that  used  by  Bryant  and  others  for  the  excision 
of  polypi  from  the  nose.  Jarvis'  ecraseur^  has  been  found  to 
work  satisfactorily.  Some  practitioners  prefer  the  galvano-cautery 
for  a  similar  operation.^ 

Dr.  Blackwood,  of  Philadelphia,*  reports  the  successful  employ- 
ment of  induced  elee;triciti/  in  the  treatment  of  chronic  post-nasal 
catarrh.  It  must  be  applied  with  care,  on  account  of  the  vicinity 
of  the  region  to  be  dealt  with  to  the  base  of  the  brain. 


Fig.  82. 


LARYNGITIS. 

Slight  inflammation  or  congestion  of  the  mucous  membrane  of 
the  larynx  is  very  common  as  the 
result  of  cold;  its  signs  being  hoarse- 
ness, with  a  dry,  short,  harsh  cough 
and  some  soreness  in  drawing  a  breath. 
But  simple  acute  laryngitis  of  severe 
grade  is  quite  a  rare  affisction. 

When  it  occurs,  there  is  fever,  with 
hoarseness,  "brassy"  cough,  distress- 
ing dyspnoea,  and  difficulty  of  swallow- 
ing. (Edema  glottidis,  or  submucous 
etlusion  of  serum,  constitutes  the  great- 
est danger  in  laryngitis  ;  the  tumefac- 
tion obstructing  respiration  to  a  degree 
often  fatal.  This  disorder  is  almost 
exclusively  met  with  in  adults. 

Early  purging,  the  application  of 
leeches,  the  internal  use  of  ipecac,  in 
doses  just  short  of  nausea,  with  mod- 
erate quantities  of  opium,  and  the  fre- 
quent inhalation  of  the  steam  of  boil- 
ing water,  constitute  the  best  treatment. 


(Edema  of  the  Glottis. 


If  dyspnoea  become 


I  Lancet,  vol.  i..  1S80,  p.  87G.  2  N.  Y.  Med.  Record,  April  30,  1881,  p.  500. 

3  Bosworth,  N.  Y.  Med.  Record,  Nov.  G.  1880,  p.  510. 

4  Monthly  Review  of  Med.  and  Pharuiacy,  January,  ISSO,  p.  8. 

19 


218      DISEASES   OF   ORGANS   OF   RESPIRATION.    . 

decidedly  serious,  threatening  asphyxia,  tracheotomy  is  advised. 
Some  account  of  tliis  operation  will  be  given  in  connection  with 
croup. 

CEdema  of  the  glottis  may  be  produced  immediately  by  the 
ingestion  of  boiling  water,  or  of  sulphuric  or  nitric  acid,  which 
has  often  accidentally  happened. 

Chronic  laryngitis,  with  ulceration,  is  a  not  infrequent  attendant 
on  phthisis.  Some  cases  of  the  latter  begin  with  it ;  in  others  it 
occurs  somewhat  late  in  the  course  of  the  disease.  An  early 
sign  in  some  cases  of  phthisis  is  (Seller^)  an  ashy-gray  discolora- 
tion of  the  mucous  membrane  of  the  pharnyx  and  larynx ; 
along  with  pyriform  swelhng  of  one  or  both  of  the  aryteroid 
cartilages  of  the  larynx.  Syphilitic  ulceration  of  the  larynx  is 
tolex'ably  common,  as  a  secondary  symptom.  This,  as  well  as 
polypi  or  other  tumors  of  the  larynx,  may  be  discovered,  and 
treated  by  operation  for  removal,  or  with  solutions  of  nitrate  of 
silver,  etc.,  through  the  aid  of  the  laryngoscope. 

My  confidence  in  the  utility  of  very  strong  solutions  of  nitrate 
of  silver  in  chronic  inflammations  of  the  mucous  membranes,  of 
the  throat  or  elsewhere,  has  not  increased,  in  fact  has  not  been 
sustained,  by  what  I  have  seen  in  practice.  Dr.  Horace  Green 
and  others  made  frequent  use  of  it  of  the  strength  of  sixty  grains 
to  the  ounce.  Except  for  ulceration,  which  may  benefit  even  by 
the  solid  caustic,  I  believe  that  from  four  to  ten  grains  in  the 
ounce  of  water  will  do  more  good,  in  almost  all  cases,  than  the 
stronger  proportions.  Iodoform  is  a  useful  local  application  for 
ulceration  of  the  fauces,  threatening  extension  to  the  larynx. 

The  application  of  nebulized  liquids,  by  apparatus  for  atomiza- 
tion,  is  now  in  vogue  in  both  acute  and  chronic  laryngitis.  Some 
remarks  upon  this  have  been  made  already,  under  General  Thera- 
peutics (Part  I.).  Vapor  of  water  containing  laudanum,  hops,  or 
hyoscyanius,  will  probably  do  the  most  good  in  laryngitis. 

APHONIA. 

Loss  of  voice  may  be  transient  or  permanent ;  and  either  func- 
tional or  structural  in  its  origin.  Especially  in  hysterical  females, 
a  nervous  shock  may  produce  a  paresis  or  enfeeblement  of  the 
vocal  jjower,  lasting  often  for  days  together.  I  saw  one  such 
case  in  which  a  young  woman  could  only  speak  in  a  whisper  for 
more  than  three  months.  A  choreic  affection  of  the  vocal  appa- 
ratus is  now  and  then  met  with ;  stammering  is,  in  fact,  analogous 
to  this ;  depending  on  a  want  of  command  and  co-ordination  of 
the  vocal  muscles. 

Faradization,  i.  e.,  the  use  of  induced  electrical  currents  (as 
magneto-electricity),  carefully  applied,  has  sometimes  cured  ner- 
vous or  hj'^sterical  aphonia.^  I  have  known  vesication  of  the  back 
of  the  neck  to  be  useful  for  it. 

Congenital  dumbness,  except  in  idiots,  is  due  to  deafness, 
making  the  learning  of  speech  impossible,  unless  by  a  recently 
invented  system  of  instruction  by  sight. 

1  Phila.  Med.  Times,  July  3,  1880. 

2  Dr.  Morell  Mackenzie  has  pointed  out  that  a  shrill  cough  or  the  slightest  dyspncua 
should  forbid  the  u.se  of  electricity  for  aphonia. — The  Pracliiioner,  vol.  ii. 


LARYNaiSMTTS    STRIDULUS.  219 

Organic  or  structural  aphonia  is  caused  by  lesions  of  tlx;  lar3mx, 
such  as  ulcerative  destruction  of  tlie  vocal  cords,  tumors,  etc., 
which  are  to  be  diagnosticated  by  l;irynno.scop3\ 

Fcitjnc.d  dunil)ne.ss  is  detectal)le  1)y  careful  watching,  or,  in  the 
last  i-esort,  by  etltcrizatinn.  In  the  stage  of  early  excitement,  or 
when  reviving  from  anaesthesia,  the  pretender  will  betray  him- 
self by  involuntary  speech. 

The  term  di/sjihoni(i  dcricorum  has  been  applied  to  an  affection 
of  the  throat  not  uncommon  among  clergymen  and  other  public 
speakers,  called  b}'  Dr.  Horace  Green  "follicular  disease  of  the 
pharyngo-lai'yngeal  membrane."  Its  symptoms  are  soreness  and 
irritation  in  the  throat,  with  disposition  to  hawk  and  spit  fre- 
quently, and  hoarseness  or  partial  loss  of  voice.  On  inspection, 
the  fauces,  pharynx,  and  glottis  are  found  to  be  of  a  reddish 
granular  appearance,  with  more  or  less  enlargement  of  the  mucous 
follicles,  and,  in  severe  cases,  a  muco-purulent  secretion  about 
the  uvula.     Sometimes,  however,  the  membrane  is  dry. 

A  conventional  treatment  for  this  affection  has  formerly  been 
the  application  every  day  or  two  of  a  solution  of  nitrate  of  silver, 
with  a  brush  or  pi-obang.  Saturated  solution  of  tannin  is  also 
used  for  it.  My  belief  is  that,  if  these  local  remedies  do  not 
begin  to  relieve  in  a  week  or  two,  the  frequent  swallowing  of 
small  pieces  of  ice,  or  gentle  gargling  several  times  a  day  with 
ice-water,  ma}'^  be  substituted  with  advantage.  Counter-irrita- 
tion over  the  throat,  especially  by  croton  oil,  should,  if  necessary, 
be  persevered  in  for  a  considerable  time.  Three  drops  of  the  oil 
(diluted  with  as  much  sweet  oil  for  a  delicate  skin)  may  be 
rubbed  over  a  limited  space  in  front  of  the  throat  every  night 
until  a  papular  eruption  comes  out.^ 

Dr.  J.  W.  Corson'^  asserts  that  relief  will  often  be  given  when 
the  voice  has  been  suddenly  lost,  by  slowly  dissolving  in  the 
mouth  and  partially  swallowing  a  piece  of  borax,  containing 
three  or  four  grains  of  the  salt.  Oil  of  eucalyptus  is,  latterly,  a 
popular  remedy  for  hoarseness. 

Many  cases  of  this  complaint  are  as  much  constitutional  as  local 
in  origin.  Where  real  dysphonia  (difficulty  or  imperfection  of 
vocalization)  exists,  liublic  speaking  or  singing  must  be  avoided, 
to  allow  the  organs  repose.  Tonics  and  change  of  air  may  often 
prove  the  best  measures  of  treatment.  (For  Aphasia^  see  Dis- 
eases of  the  Brain.) 

LARYNGISMUS  STRIDULUS. 

This  is  an  infantile  affection,  consisting  in  spasmodic  closure  of 
the  glottis,  causing  a  stridulous  or  shrill  whistling  respiration.  It 
is  most  apt  to  occur  during  dentition,  but  is  not  very  common.  Its 
onset  issudden,  and  its  duration  bi'ief.  Though  exceedingly  alarm- 
ing, it  is  seldom  fatal.  Of  52  cases  recorded  by  Prof.  Henoch,  of 
Berlin,  33  were  between  9  and  30  months  of  age,  and  19  between 
2  and  9  months. 

The  treatment  must  be  prompt ;  producing  derivation  by  slap- 
ping the  back  and  limbs,  and  putting  the  feet  into  hot  water,  while 

1  Patients  should  be  cautioned,  of  couise,  against  allowing  the  oil  to  come  near  the 
eyes.    I  have  known  a  severe  ophthalmia  to  result  from  neglect  of  this. 
3  N.  Y.  Medical  Kecord,  Jan.  1,  lS7a. 


220      DISEASES   OF   ORGANS   OF   RESPIRATION. 

cold  water  is  applied  to  the  head.  Trousseau  advised  the  applica- 
tion to  the  throat  (better  the  nucha)  of  a  sponge  dipped  in  quite 
hot  water.  In  severe  cases  mustard  plasters  (diluted  with  flour) 
may  be  applied  to  the  chest  and  back.  Some  advise  the  momentary 
inhalation  of  chloroform ;  others  (Charon,  Henriette)  of  ammonia. 
When  life  is  really  in  great  danger  from  prolongation  of  the  spasm, 
tracheotomjr  may  be  Justifiable.  Dr.  Polk,'  of  N'ew  York,  saved 
one  child's  life  by  the  introduction  of  a  JS'o.  8  silver  catheter. 
Children  who  have  laryngismus  are  generally  aneemic  ;  requiring 
iron  [F.  23]  (perhaps  bromide  of  potassium)  and  salt  baths. 

CROUP. 

We  understand  by  croup,  an  acute  cynanche  or  angina,  whose 
signs  are,  a  hoarse  cough— ditficult  and  audible  respiration,  and 
aphonia ;  the  seat  of  the  disorder  being  the  upper  portion  of  the 
air-passages.  Its  place  in  nosology  has  been  empirically  or  con- 
ventionally (rather  than  systematically)  established. 

The  identity  of  membranous  croup  with  diphtheria,  asserted  by 
Dr.  J.  F.  Meigs  and  many  others,  appears  to  me  to  be  disproved, 
by  a  distinctness  of  history  and  pathology  too  signal  to  be  put 
out  of  view.  The  one  (croup)  is  a  sporadic  local  inflammation, 
mostly  sthenic ;  the  other  (diphtheria)  is  an  epidemic  constitu- 
tional affection,  with  local  symptoms  ;  mostly  asthenic.  As  IS^ie- 
meyer^  points  out,  also,  in  croup  the  exudation  is  thrown  out  itxjon 
the  epithelial  surface  of  the  mucous  membrane,  while  in  diphtheria 
it  forms  also  within  its  stibstance.  Of  other  authorities,  we  find 
among  those  holding  the  doctrine  of  the  identity  of  membranous 
croup  with  diphtheria.  Sir  Thomas  Watson,  Hillier,  George  John- 
son, and  Morell  Mackenzie.  On  the  other  hand,  the  frequent 
occurrence  of  cases  of  inflammatory,  pseudo-membranous  croup 
not  identical  with  diphtheria,  is  maintained  by  such  writers  as 
Spence,  Squire,  C.  West,^  Hogg,  Virchow,  Hassenstein,  Oertel, 
Oppolzer,  ISTiemeyer,  Trendelenburg,  and  Letzerich,  abroad ;  and 
G.  B.  Wood,  A.  Flint,  J.  Lewis  Smith,  Fordyce  Barker,  and  Cohen, 
in  this  country. 

For  brevity's  sake,  the  following  propositions  may  be  ad- 
vanced :— 

1.  The  pathological  elements  of  croup  are,  a,  spasm  ;  ft,  hyper- 
semia  or  congestion ;  c,  inflammation,  either  ordinary  or  diph- 
theritic. 

The  spasm  affects  especially  the  muscles  whose  action  tends  to 
close  the  rima  glottidis  ;  but  may  involve  also  the  muscular  coat 
of  the  trachea  itself. 

The  hyperismia  commences  in  the  mucous  membrane  of  the 
larynx  or  trachea,  but  often  extends  throughout  the  whole  anterior 
cervical  region. 

The  inflammation  may  be  located  in  a  small  portion  of  the  same 
mucous  membrane,  or,  it  may  extend  downwards  indefinitely  into 
the  bronchial  tubes. 

2.  We  may  mentally  distinguish  between  cases,  in  which  the 
croupal  dyspnoea  results  from  simple  spasm,  from  simple  tumefac- 

l  N.  Y.  Med.  Record,  June  19,  1880,  p.  709. 

B  Text-book  of  Practical  Medicine  (transl.,)  vol.  1.,  p.  15. 

8  Until  recently ;  not  now  (1881). 


CROUP. 


221 


tion,  or  from  iiidaniniulion  williout  any  spasmodic  constriction  of 
the  glottis.  But,  in  practice,  the  pathognomonic  cough  and  breath- 
ing  rarely  attend  such  an  isolation  of  one  of  these 
conditions.      A   certain   number  of  cases,  however,      Fig.  83. 
occur,  of  purely  spasmodic  or  nervous  croup  ;  now  and 
then  substituting  more  general  convulsions  ;  as  when 
worms  have  been,  apparently,  an  exciting  cause.     A 
purely  inllammatory  case  is  at  least  equally  rare.    In 
fatal  pseudo-membranous  cases,  autopsic  examination 
has  repeatedly  shown  that  the  amount  of  false  mem- 
brane   was    by  no  mi>ans   sufficient,    alone,    to  have 
occluded  the  larynx  or  trachea ;  the  result  being  due 
to  the  additional  spasmodic  contraction. 

3.  The  most  frequent  form,  common  night  croup, 
is  pathologically  characterized  by  spasm  of  the  glot- 
tidcan  ai)paratus,  with  congestion  and  tumefaction 
(transient  in  character),  of  the  laryngo-tracheal  mu- 
cous membrane. 

It  is  in  these  respects  precisely  analogous  in  nature 
to  the  asthmatic  attack,  whose  seat  is  in  the  smaller 
air-tubes.  There  is  no  strongly  marked  line  of  sepa- 
ration between  this  form  and  the  catarrhal  croiq),  or 
croupal  catarrh,  in  which  more  or  less  active  inflam- 
mation occurs,  prolonging  the  existence  of  the  symp- 
toms. _        _ 

4.  Looking,  then,  on  the  hypertemic  state  as  simply  pg^jgg  Mem- 
intermediate,  we  may  classify  the  cases  of  croup,  as  brane  iu 
they  ordinarily  occur,  clinically,  as,  1st,  those  in  which  Trachea, 
spasm  predominates;  and  2dly,  those  in  which  inflam- 
mation is  the  dominant  condition ;  or,  bearing  in  mind  the 
above  expressed  qualification,  into  spasmodic  and  inflamma- 
tory cases. 

5.  Pseudo-membranous,  or  "true  croup,"  does  not generically 
dift'er  from  inflammatory  croup ;  of  which  it  is  only  a  grade  or 
termination:  i.  e.,  any  case  of  inflammatory  or  catarrhal  croup 
may  end  in  the  exudation  of  coagulable  lymph  within  the  air- 
tubes. 

6.  Whether  this  shall  occur  or  not,  in  any  given  case,  depends, 
a,  on  the  degree  of  the  inflammation  ;  6,  on  the  state  of  the  blood 
of  the  patient ;  c,  on  the  treatment. 

7.  It  cannot  be  predicated  on  the  ground  of  experience,  that 
either  vigorous  and  plethoric,  or  feeble  and  anaemic  children,  are 
especially  prone  to  the  membranous  form  or  termination  of  inflam- 
matory croup.     It  may  and  does  occur  frequently  in  both. 

8.  The  ordinaril}^  recognized  signs  for  the  diagnosis  of  inflam- 
matory from  uon- inflammatory  croup  are  sufficient,  viz.,  the 
persistent  duration  of  the  croupal  cough  and  voice — the  (gen- 
erally) slow  onset — the  febrile  sj'mptoms  —  and  the  stridulous 
inspiration,  as  the  dyspnoea  increases. 

9.  Inflammatory  or  true  croup  is,  with  the  above  inclusion  (as 
always  potentially  membranous),  not  at  all  necessarily  fatal, 
although  highly  dangerous.  The  presence  of  the  false  mem- 
brane itself  does  not  inevitably  determine  a  fatal  result.     Heart- 

19* 


222 


DISEASES   OF   ORGANS   OF   RESPIRATION. 


Fig.  84. 


clot,  from  embarrassment  of  the  circulation,  has  sometimes  hast- 
ened death.' 
10.  In  no  disease  does  more  depend  on  early  treatment,  which  Is 
often  prevented  hy  the  insidious 
approach  of  the  attack  deluding  the 
parents.  The  mortality  of  the  dis- 
ease may  thus  in  part  be  accounted 
for. 

11.  In  the  treatment  of  all  forms 
of  croup,  relaxation  and  secretion  are 
the  two  great  desiderata. 

12.  In  the  spasmodic  cases,  emetics 
and  antispasmodics  (e.  gf. ,  ipecacuan- 
ha, onion,  assafoetida,  or  lobelia)  will 
eftect  these  objects,  especially  if 
aided  by  the  warm  bath  or  foot  bath. 

13.  In  mild  inflammatory  cases, 
saline  purging,  gentle  vomiting,  and 
the  use  of  demulcents,  counter-irri- 
tation, and  pediluvia  will  relieve. 

14.  In  the  more  active  cases,  the 
loss  of  blood  by  the  lancet,  or  by 
leeching,  or  by  both,  will  be  neces- 
sary, and  should  be  early  used.'^ 

15.  The  most  satisfactory  emetic 
for  employment  in  such  cases  is  a 
combination  of  ipecac  and  alum  [F. 
24] ;  the  latter  being  used  in  half  tea- 
spoonful  doses  in  urgent  cases,  until 
emesis  is  produced.  ISTor  should  the 
practitioner  hesitate  to  compel  re- 
peated vomiting  at  intervals,  in  des- 
perate cases.  Better  for  a  child  to 
risk  being  sick  for  a  month,  than  to 
die  of  cynanche  (dog-choke,  as  the 
Greeks  termed  it).  But  the  alum  is 
unlikely  to  do  harm.  Turpeth  min- 
eral is  preferred  by  some. 

16.  Tartar  emetic  should  not  be 
used   as  an    emetic    in    croup ;   in 

sedative  or  expectorant  doses,  it  may  be  advantageous.  The 
same  may  be  said  of  veratrum  viride,  pilocarpin,  and  apomorphia; 
each  of  which  is  greatly  promotive  of  relaxation,  but  also  of  seri- 
ous depression.  Cure  has  been  effected  in  a  desperate  case,  by 
the  hypodermic  injection  of  -^^  grain  of  hydrochlorate  of  apo- 
morphia. For  a  child  the  dose  must  be  small,  and  its  action 
must  be  watched  before  repetition.  A  case  has  been  reported^ 
in  which  life  appeared  to  be  saved  by  the  hypodermic  injection 
of  three  drops  of  a  one  per  cent,  solution  of  sulphate  of  atropia. 

1  B.  W.  Kichardson,  Med.  Times  and  Gazette,  March,  1856. 

2  Dr.  F.  Barker  employs,  instead,  ii7ict.  veratr.  vivid,  in  one  or  two  drop  doses ;  some- 
times combined  with  carbonate  of  ammonium,  and  followed  by  large  doses  of  quinine 
in  severe  cases. — Am.  Journal  of  Obstetrics,  May,  1870. 

2  De  Ponteves;  L'Union  Miidicale,  1879. 


Bronchial  False  Membrane. 


CROUP.  223 

17.  Calomel  [F.  25],  freely  administered,  that  is,  a  grain  every 
hour  or  two,  has  the  highest  authority  in  its  favor,  in  serious 
croup. 

18.  Nitrate  of  potassium  has  hoth  experience  and  reason  in  its 
favor.  ]^eing  a  solvent  of  lihrin,  it  may  tend  to  prevent  the  exces- 
sive coagulability  of  the  exudation.  According  to  late  theories, 
ammonia  might  do  the  same  thing ;  but  the  clinical  or  therapeutic 
antecedents  of  ammonia  point  otherwise.  Of  the  lately  asserted 
value  of  sulphur  in  croup,  I  have  no  experience.  3)r.  Ozanam 
i-eports  great  success  with  bromine  solution  (one  drop  in  an  ounce 
of  water),  a  few  drops  every  hour  ;  using  also  the  bromine  water 
and  bromide  of  potassium  by  inhalation  with  boiling  water. 

19.  The  great  evil  in  membranous  croup  is  the  solidifying  ten- 
dency of  the  exudation ;  why  should  not,  therefore,  an  abundant 
imbibition  of  liuids,  even  of  water,  do  something  towards  counter- 
acting this  y  Inhalation  of  steam,  from  hot  water  poured  upon 
unslaked  lime,  is  eulogized  by  several  writers.  Glycerin,  in  tea- 
spoonful  or  half  teaspoouful  doses,  is  recommended  by  E.  Ilarts- 
horne  and  others.  Lactic  acid,  found  by  Bricheteau  to  be  a 
powerful  solvent  of  false  membranes,  has  been  applied  locally,  in 
solution,  with  success,  by  Dr.  Dureau.^  Keeping  the  air  warm 
(over  70°,  some  say  80°  or  90°)  and  moist  around  the  patient  is 
advised  by  several  practitioners. 

20.  No  clear  indication  exists  for  the  use  of  opium  in  the  major- 
ity of  cases  of  inflammatory  or  membranous  croup ;  although  it 
may  become  useful,  in  cases  which  are  protracted,  or  which  are 
attended  by  a  more  than  usual  disposition  to  spasmodic  symptoms. 
Tlie  objection  to  it,  in  my  mind,  is,  its  tendency  to  diminish  bron- 
chial (or  tracheal)  secretion;  which,  in  croupal  affections,  we 
desire  especially  to  promote. 

21.  Blisters  are  decidedly  useful ;  but  they  should  not  be  left  on 
long  in  croup,  a  superficial  vesication  only  being  desired.  With 
Trousseau,  a  favorite  application  was  a  sponge  or  compress  dipped 
in  hot  water  and  applied  to  the  throat. 

22.  The  application  of  a  strong  solution  of  nitrate  of  silver  [F. 
2G]  to  the  fauces  (and  larynx,  if  possible),  does  good  in  many 
cases  ;  in  the  pre-exudative  stage  as  a  medicament ;  in  the  exuda- 
tive, as  a  mechanical  operation  aiding  to  dislodge  the  membrane. 

23.  Iodide  of  potassium  is  too  slow  in  its  systemic  action  to  be 
relied  on ;  and  the  same  may  be  anticipated  of  the  bromide ; 
although  nothing  should  forbid  their  fair  trial. 

2-1.  Tracheotomy  or  laryngotomy  will,  when  performed  early, 
succeed  in  a  fair  number  of  cases  ;  but  in  many  of  those  cases  it 
is  impossil)le  to  know  that  they  (as  well  as  some  in  which  it  fails) 
might  not  have  recovered  without  it.  Few  practitioners,  there- 
fore, in  this  country,  can  demand  the  operation  early  ;  and  in  the 
moribund  state,  the  vascular  congestion,  from  asphyxia,  about 
the  tbroat,  renders  success  difficult,  sometimes  impossible.  Upon 
the  whole,  therefore,  the  cases  in  which  the  operation  may  be 
expected  to  add  to  our  hope  in  croup,  are  few\  In  1859,  Bouchut, 
of  Paris,  introduced  tubage  (or  catheter-like  dilatation  of  the 


1  Bulletin  General  Therapeutique,  Sept.  15,  18GS. 


224      DISEASES  OF   ORGANS   OF   RESPIRATION. 

larynx  and  trachea)  instead  of  tracheotomy,  at  the  same  time 
publishing  some  statistics  very  unfavorable  to  tracheotomy. 
The  Academie  Imperiale  de  Medecine,  however,  decided  ad- 
versely to  the  use  of  tubage  as  a  substitute  for  tracheotomy. 
An  instance  of  the  successful  employment  of  a  common  catheter 
was  reported  by  Dr.  Paton  (Brit.  Med.  Journal,  vol.  i.,  1881,  p. 
803). 

My  own  experience  with  tracheotomy  has  not  been  encouraging. 
"With  Dr.  C.  West,  who  had  but  one  recovery  in  sixteen  cases,  I 
am  obliged  to  admit  its  success,  in  some  otherwise  hopeless 
instances ;  especially  in  France,  where  Trousseau  and  others 
have  operated  earlier  than  in  England  or  here.^  It  is  most  often 
fatal  in  children  under  three  years  of  age.  Where  there  is  reason 
to  believe  the  membrane  to  extend  into  the  bronchial  tubes,  it  is 
of  course  in  vain.  The  danger  of  hemorrhage,  from  dilated  blood- 
vessels especially,  is  least  if  the  operation  be  early.  Dr.  Aitken 
thinks  that  it  ought  always  to  be  performed  if  no  symptoms  of 
amelioration  follow  active  treatment,  by  "bleeding,  emetics,  the 
warm  bath,  and  calomel  purgation"  steadily  pursued  for  twelve 
or  sixteen  hours.     The  suggestion  is  a  good  one,  that  the  opera- 

FiG.  85. 


Durham's  Canula  and  Pilot. 

tion  is  most  appropriate  when  the  tendency  to  death  is  more  hy  con- 
tinuous apnoea  than  hy  exhaustion."^  If  delayed  too  long,  the  apnoea 
itself  may  iiroduce  an  irremediable  condition. 

If  performed,  it  should  be  deliberate,  tying  every  vessel  that 
bleeds,  making  a  considerable  opening  in  the  upper  rings  of  the 
trachea,  and  inserting  a  tube  or  canula^  of  good  size.     Some 

1  Nfilaton's  first  operation  was  successful;  he  then  had  twenty-three  cases  without 
one  success.  N.  Y.  Med.  Record,  June,  1869.  From  statistics  published  by  Jacob! 
and  others,  it  appears  that  of  1024  operations  of  tracheotomy,  in  Europe  and  this 
country,  220,  or  21.48  per  cent.,  have  been  followed  by  recovery.  During  the  years 
1861-1872  inclusive,  there  were  performed  in  the  department  of  Prof.  Wilms,  in  Berlin, 
330  tracheotomies  on  diphtheritic  patients  under  16  years  of  age.  Up  to  2  years  of  age 
there  were  6  operations,  and  all  died.  In  the  ages  of  2-3  years,  there  were  56  opera- 
tions, 15  recovered;  3-4  years,  69,  22  recovered;  4-5  years,  74,  18  recovered;  5-6  years, 
57,  20  recovered;  6-7  years,  33,  15  recovered;  7-8  years,  21,  5  recovered;  8-14  years,  19, 
8  recovered ;  total,  103  recoveries  (31-^  per  cent.)— boys,  36§  per  cent.,  girls,  24J  per  cent. 
In  the  first  two  years,  and  between  the  ages  11-14  inclusive  (of  each  6),  not  a  case  recov- 
ered.   Successes  under  one  year  have,  however,  been  reported. 

"  Dr.  G.  Buchanan,  Brit.  Med.  Journal,  March  4,  1871. 

3  F.  Howard  Marsh  (Reports  St.  Barthol.  Hosp.,  vol.  iii.)  asserts,  after  careful  measure- 
ments, that  the  diameter  of  the  trachea  is,  before  two  years  of  age,  10-40ths  of  an  inch ; 
in  the  third  year,  ll-40ths;  between  this  and  the  seventh  year,  14-40ths.  Acanulamay 
be  9-40ths  of  "an  inch  for  a  child  under  four  years;  ll-40ths  between  five  and  eight,  and 
12-40ths  from  that  to  twelve  years  of  age.  Durham's  canula  is  probably  the  best  now 
in  use.  Luer's  silver  canula,  movable  on  the  shield,  is  preferred  by  some;  others  use 
Leiter's  hard-^'uhher  canula. 


CROUP. 


225 


operators  excise  a  small  portion  of  one  or  two  tracheal  rings. 
Others,  instead  of  a  canula,  use  a  leaden  wire  passed  around  the 
neck,  its  ends  being  hooked  into  the  sides  of  the  opening.  A 
bivalve  dilator  (Trousseau's  or  Hutchinson's)  sliould  be  inserted 
soon  after  the  trachea  is  opened.  R.  W.  Parker  (Medico-Chirur- 
gical  Transactions,  1879)  advises  that  a  feather  sliould  be  used 
to  clear  the  trachea  of  membrane  before  inserting  the  tube. 
Sometimes  medicated  solutions  are  tbus  introduced  ;  as  (Trous- 
seau) l)icarbonate  of  sodium,  or  persulphate  of  iron  with  glycerin, 
etc.  In  the  adult,  Arnott  and  others  have  used  a  curved  trocar; 
Marshall  Ilall,  scissors.  The  use  of  chloroform  or  ether  will 
facilitate  the  operation ;  the  danger  from  the  inhalation  is  least 
when  the  vitality  of  the  patient  is  not  yet  greatly  reduced. 
Some  have  observed  partial  anaesthesia  of  the  skin  to  be  a  sign 
of  increasing  asphyxia,  such  as  indicates  the  propriety  of  the 
operation.  lictraction  of  the  chest-wall  during  inspiration  is  yet 
more  significant  of  danger  to  life  from  failure  of  breathing. 
After  trach(;otomy,  the  patient  should  be  surrounded  constantly 
with  a  warm,  moist  atmosphere.  The  canula  should  be  witli- 
drawn  in  as  few  days  as  possible,  upon  the  return  of  permeability 
of  the  larynx.     The  wound  may  then  be  treated  with  ordinary 


Bry nut's  Cauula.     A.  Full  length.    B.  Shortened. 

mild  dressings,  to  exclude  the  air  and  heal  it  up.  Yerneuil,  Saint 
Germain,  Ranse,  Muron,  and  Boeckel  have  advocated  trache- 
otomy with  the  actual  cautery.  Its  especial  advantage  is  said  by 
them  to  be  the  division  of  the  tissues  exterior  to  the  trachea.,  by 
means  of  a  knife  at  a  dull  red  heat,  without  the  danger  and  delay 
of  hemorrhage.  They  sometimes  divide  the  trachea  itself  with 
a  common  bistoury ;  separating  the  edges  of  the  wound  with  a 
dilator  to  insert  the  canula.  Another'method  proposed  (Reis- 
mann,  1879)  for  "  bloodless  tracheotomy"  is,  to  introduce  sutures 
through  all  the  tissues  along  the  sides  of  the  incision  made,  before 
the  trachea  is  opened. 

The  fact  that  lime  will  dissolve  false  membranes  has  been 
largely  applied  to  the  treatment  of  croup  ;  by  making  the  patient 
breathe  the  steam  from  boiling  water  poured  over  unslaked  lime. 
Altliough  the  lime  is  not  vofatile,  some  of  its  minute  particles 
will  be  raised  mechanically  by  agitation.  Several  successful 
cases  of  its  use  are  reported.  Prolmbly  the  absorption  of  the 
carbonic  acid  of  the  breath  ma}^  partly  explain  the  usefulness  of 
lime.     Kuhn,  however,  asserts  that  carbonate  of  potassium,  given 

P 


226      DISEASES   OF   ORGANS   OF   RESPIRATION. 

early,  will  prevent  the  formation  of  false  membrane.  Lactic  acid 
(inhalation  of  a  solution  of  20  drops  in  half  an  ounce  of  water) 
has  been  used  with  success  (Adolph  Weber)  in  croup, ^ 

To  sum  up,  I  would  begin  the  treatment  of  a  case  of  inflamma- 
tory croup  with  a  saline  purgative.  Then  an  emetic  of  ipecacu- 
anha ;  which  may  have  to  be  repeated.  Leeching,  and  even 
venesection,  will  be  useful  in  a  robust  subject  if  seen  early. 
Between  the  times  of  emesis,  there  may  be  prescribed  1  grain  of 
calomel  with  5  grains  of  nitrate  of  potassium,  every  two  hours ; 
in  urgent  cases  every  hour.  In  children  over  three  years  of  age 
ri  to  jig  grain  tartar  emetic  may  be  added  ;  or  one-drop  doses  of 
tincture  of  veratrum  viride  ;  watching  the  effect  produced.  The 
warm  bath,  prolonged,  may  be  used  once  or  twice  daily.  Hot 
compresses,  or  cloths  wrung  out  of  cold  water  (which  soon  be- 
comes warm  when  applied)  may  be  applied  to  the  throat ;  but  a 
blister  should  follow  in  a  severe  case.  Inhalation  of  steam  from 
lime  or  lactic  acid  should  be  tried,  early  as  well  as  late.  Alum 
must  be  added  to  ipecac,  if  relief  be  delayed,  Nitrate  of  silver 
siDonging,  and  catheterism  or  tracheotomy,  are  last  resorts. 

The  following  conclusions  are  laid  down  by  Dr.  J.  S,  Cohen, 
in  his  monograph^  upon  Croup  and  Tracheotomy : 

"  1,  There  are  no  insuperable  contra-indications  to  trache- 
otomy in  croup. 

"2.  The  administration  of  an  ansesthetic  for  the  purpose  of 
controlling  the  child's  movements  is  admissible  in  performing  the 
operation ;  but  it  should  be  used  with  great  caution. 

"3.  A  careful  dissection  should  be  made  down  to  the  windpipe, 
and  hemorrhage  be  arrested  before  incising  it,  whenever  there  is 
at  all  time  to  do  so. 

"4,  The  incision  should  be  made  into  the  trachea  as  near  the 
cricoid  cartilage  as  possible,  to  avoid  excessive  hemorrhage,  and 
subsequent  accidents  which  might  occasion  emphysema, 

"  5.  A  dilator  should  be  used,  or  a  piece  of  the  trachea  be 
excised,  whenever  any  difficulty  is  encountered  in  introducing 
the  tube. 

"  6,  The  tube  should  be  dispensed  with  as  soon  as  possible  ;  or 
altogether  if  the  case  will  admit  of  it. 

"7,  Assiduous  attention  should  be  bestowed  upon  the  after- 
treatment,  especially  that  of  the  wound.  A  skilled  attendant 
should  be  within  a  moment's  call  for  the  first  twenty-four  or 
forty-eight  hours  immediately  following  the  operation," 

The  diagnosis  between  inflammatory  croup  and  diphtheria  will 
be  referred  to  hereafter,  in  connection  with  the  latter  disease, 

PLEURODYNIA. 

Synonym. — Intercostal  Rheumatism. 

Symptoms, — Pain,  generally  i-ather  dull,  sometimes  quite  se- 
vere, oY  one  or  both  sides,  oftenest  on  the  left.  It  is  increased 
by  deep  breathing  or  coughing,  moving  the  arms  or  trunk. 

Diagnosis. — From  pleurisy,  it  is  known  by  the  absence  of  fever, 
and  of  all  modifications  of  the  sounds  heard  upon  percussion  and 
auscultation, 

1  Med.  Times  and  Gazette,  Jan.  22, 1870.  2  Philada.,  1874. 


PHTHISIS    PULMONALIS.  227 

Treatment. — A  lai-gc  mustard  plaster  over  the  part ;  friction 
with  soa})  or  volatile  or  some  anodyne  liniment ;  dry  or  cut  cui)s  ; 
covering-  the  side  with  carded  wool  and  oiled  silk;  a  belladonna 
plaster ;  a  blister  if  obstinate  as  well  as  severe. 

INTEKCOSTAL  NEURALGIA. 

Symptoms. — Severe  lacerating  pains  between  the  sixth  and 
ninth  or  tenth  ribs,  along  the  intercostal  spaces ;  frequently  inter- 
mitting, or  even  regularly  periodical.  This  aftection  is  most 
generally  met  with  in  ansemic  patients,  or  in  those  who  have 
been  exposed  to  malarial  intluence.  Occasionally  the  paroxysms 
are  attended  by  a  sort  of  reflex  pulmonary  congestion,  simulat- 
ing pleuro-pneumonia.     Spinal  tendeimc.^s  is  often  present. 

Treatment. — A  sinapism  may  be  applied  ;  or  ointment  of  aconite 
[F.  27],  or  of  chloroform  [F.  28],  or  veratria  [F.  29],  may  be 
rubbed  upon  the  side  during  the  paroxysm.  Should  these  not 
relieve,  a  small  blister  may  be  allowed  to  vesticate,  and  then  one 
or  two  grains  of  acetate  of  morphia  diluted  with  powder  of 
gum  arable  may  be  applied  to  the  surface  ;  or  solution  of  mor- 
phia may  be  used  hj  hypndemdc  injection^  half  a  drachm  at  a  time 
being  introduced  by  means  of  a  syringe  adapted  to  the  purpose, 
over  the  part. 

General  treatment,  by  iron,  quinia,  or  ciuchonia,  etc.,  will  be 
determined  by  the  condition  of  the  patient. 

THORACIC  MYALGIA. 

This  term  has  been  applied  (Tnman)  to  an  affection  characterized 
by  pain  in  the  superficial  muscles  of  the  chest,  mostly  dependent 
upon  ill-nourishment  and  overwork  ;  sometimes  produced  by  con- 
strained positions  of  the  body,  or  pressure  ;  as  by  a  desk,  or  a 
soldier's  belt,  etc. 

Its  treatment  consists  in  the  removal,  if  possible,  of  its  cause  ; 
with  local  warming  or  anodyne  applications,  and  general  invigora- 
tion  of  the  system. 

PHTHISIS  PTJLMONALIS. 

Definition. — Tuberculous  or  caseous  consumption  of  the  lungs. 

Varieties. — Acute,  chronic,  and  latent  phthisis. 

Symptoms  and  Course. — Consumption  may  begin  after  a  severe 
acute  bronchitis  or  broncho-pneumonia ;  or,  more  gradually, 
with  an  apparently  slight  hacking  cough  ;  or  with  a  hemorrhage  ; 
or  with  dyspepsia  and  general  debility  ;  or  with  chronic  laryngitis. 
Increasing,  in  most  cases  slowly,  the  pectoral  and  constitutional 
disorder  becomes  developed.  We  have,  then,  pains  in  the  chest, 
frequent  and  severe  cough,  hemorrhage  occasitmally  (in  about 
two-thirds  of  the  cases)  and  pallor,  acceleration  of  the  pulse  and 
elevation  of  the  temperature,  with  the  paroxysms  of  hectic  fever, 
i.  e.,  chills  followed  by  fever  with  bright  flush  of  cheek,  but  with- 
out headache  ;  emaciation,  arrest  of  menstruation  in  the  female, 
night-sweats,  colliquative  diarrlitea;  finally,  often,  though  not 
always,  delirium  ;  and  death,  mostly  by  exhaustion,  but  some- 
times 1)}^  sullbcation.  The  spirits  of  the  patient  are  apt  to  be 
cheerful,  even  hopeful  of  life  almost  to  the  last.     Appetite  is 


228      DISEASES   OF   ORGANS   OF   RESPIRATION. 

variable,  cligestioa  usually  not  vigorous  ;  but  to  this  there  are 
exceptions. 

The  following  description  of  advanced  phthisis  is  from  the  late 
Prof.  ]Sr.  Chapman  : 

"  The  cheeks  are  hollow,  the  bones  prominent,  the  skin  arid, 
the  nose  sharpened  aiid  drawn,  the  eyes  sunken,  with  the  adnata 
of  a  pearl  color,  destitute  of  vascularity,  the  lips  retracted,  so  as 
to  produce  a  bitter  smile,  and  the  hair  thinned  by  falling  out,  the 
neck  wasted,  oblique,  and  somewhat  rigid  or  immovable,  the 
shoulder-blades  projected  or  winged,  the  ribs  naked  or  exposed, 
with  diminution  of  the  intercostal  spaces,  and  the  thorax  appa- 
rently narrowed ;  the  abdomen  flat,  the  joints,  great  and  small, 
seemingly  enlarged  from  the  wasting  of  the  integuments,  the 
nails  livid  and  occasionally  incurvated,  the  extremities  oedema- 
tous ;  the  angular  points  on  which  the  body  rests,  in  several 
points  protruded  through  the  skin — the  whole  attended  by  a 
most  afflicting  cough,  aphthae,  sore  throat,  difflcult  deglutition, 
and  feeble,  whispering  voice,  or  entire  extinction  of  it." 

The  expectoration  in  phthisis  is  at  first  mucous  or  bloody  ;  later, 
muco-purulent  and  bloody,  or  else  nummular;  i.  e.,  in  roundish 
masses  like  coins,  not  floating  perfectly  in  water ;  or,  al)undant 
and  purulent.  Dr.  T.  Thompson  first  noticed  (1852)  the  appear- 
ance of  a  rather  deep-red  line  along  the  gums  as  one  of  the  signs 
of  phthisis. 

Stages. — These  are,  1.  Incipient  phthisis  ;  2.  The  stage  of  con- 
solidation of  the  lung  ;  3.  That  of  excavation  or  vomicce  ;  4.  Ad- 
vanced or  confirmed  consumption. 

Piiysieal  Signs.— The  earliest  indications  upon  physical  explora- 
tion are,  a  sinking  in  under  the  clavicle  upon  the  left  side,  with 
prolonged  expiratory  sound.  Not  long  after,  the  evidence  of  con- 
solidation is,  increased  dulness  over  the  apex  of  the  lung  upon 
percussion  (not  invariably,  but  generally  upon  the  left  side)  with 
blowing  or  bronchial  respiration,  or  interrupted  jerking  respira- 
tory murmur,  and  increased  vocal  resonance  and  vibration.  Dry 
crackling  follows,  with  mucous  or  coarse  crepitant  rale. 

When  softening  of  tubercular  deposits  occurs,  moist  crackling 
and  gurgling  become  very  distinctive  signs.  The  presence  of  a 
vomica  is  shown  by  cavernous  respiration  and  bronchophou}^  or 
pectoriloquy.  Percussion-resonance  over  a  cavity  will  be  dull  if 
its  walls  be  thick,  and  amphoric  if  they  are  thin  and  tense  ;  if 
thin  and  relaxed,  the  bruit  depotfeU  or  cracked-pot  sound.  On 
percussion  over  a  cavity  when  the  patient's  mouth  is  shut,  the 
sound  produced  may  be  of  a  lower  pitch  than  when  the  mouth 
is  open. 

Pneumothorax  and  hydro-pneumothorax,  i.  e.,  dilatation  of  the 
pleural  cavity  and  compression  of  the  lung  by  air,  or  air  and 
liquid  together,  with  perforation  of  the  lung,  are  not  uncommon 
results  of  tuberculization,  although  possible  without  it.  Of  pneu- 
mothonix,  the  percussion-resonance  is  tympanitic  ;  respiratory 
murmur  is  lost.  Hydro-pneumothorax  may  give  t3"mpanitic  reso- 
nance above,  v/ith  metallic  tinkling  on  auscultation,  and  dulness 
below. 

Physical  and  Microscopical  Peculiarities.— Temperature  has 


PHTHISIS     PU  I.MON  A  LIS.  229 

been  found  to  be  a  diagnostic  aid  in  phthisis.  It  is  asserted  that 
there  is  a  continued  elevation  of  the  heat  of  the  hodi/  in  all  cases  in 
which  tubercle  is  being  dcpofjited  ;  that  this  may  occur  for  weeks 
before  any  local  physical  sign  is  discoverable ;  and  that  the  rise 
in  the  heat  of  the  body  varies,  during  the  progress  of  the  case, 
with  the  greater  or  less  activity  of  the  tuberculization.  It  has 
been  shown,  however,  that  exceptions  to  this  general  rule  do 
occur  ;  and  it  is  not  certain  whether  the  elevation  of  temperature 
is  not  due  really  to  a  concomitant  irritative  or  sub-inliammatory 
process,  rather  than  to  the  simple  deposit  of  tubercle.  This  last 
is  the  most  probable  view. 

When  expectoration  is  copious,  some  micrologists  aver  that 
diagnosis  may  be  aided  by  its  minute  characters  ;  arched  and 
anastomosing  fragments'  of  pulmonary  fibrous  tissue,  and  tuber- 
cular corpuscles,  being  discerned.  But  it  is  not  proven  that  the 
former  are  thrown  off  only  in  phthisis ;  and  the  latter  may  be 
absent  or  obscure  in  character  in  an  otherwise  clear  case.  Nie- 
meyer  regarded  the  presence  of  elastic  fibres  in  the  sputa  as  a 
sure  indication  of  consumption.  Dr.  Fenwick,  of  London,  detects 
minute  portions  of  lung-tissue  by  boiling  the  expectoration  a  few 
minutes  with  its  bulk  of  solution  of  caustic  soda  (gr.  xv  in  f  §  j  of 
distilled  water),  and  adding  cold  water,  in  a  conical  vessel.  The 
sediment  is  then  examined  with  the  microscope. 

Terminations. — The  cicatrization  of  vomicae,  and  the  cessation 
of  tubercular  deposition,  have,  although  exceptional,  been  often 
found  to  occur ;  and  so  have  the  cornification  and  calcification  of 
unsoftened  tubercle.  Recovery  from  phthisis  may  in  such  cases 
be  expected  to  take  place,  as  the  arrest  of  the  local  disease  attends 
the  presence  of  a  favorable  constitutional  state. 

Death  from  consumption  may  come  by  asthenia  or  by  apnoea. 
The  first  is  most  common.  Suffocation  or  apncea  may  follow— 1, 
from  hemorrhage  ;  2,  rupture  of  a  large  vomica ;  3,  pulmonary 
OBdema  or  hydrothorax  ;  4,  excessive  secretion  or  bronchorrhoea, 
beyond  the  power  of  expectoration. 

Complications. — Pleurisy  is  a  frequent  concomitant  of  phthisis. 
Tubercular  peritonitis  is  much  more  rare.  On  account  of  its  dura- 
tion, however,  pulmonary  consumption  may  be  accidentally  com- 
bined with  various  affections  not  specially  kindred  with  it. 
Asthma  is  particularly  not  apt  to  be  conjoined  with  phthisis. 

Diagnosis. — It  is  from  chronic  bronchitis,  cancer  of  the  lung, 
pleuritic  effusion,  bronchial  dilatation,  and  pulmonary  abscess 
that  phthisis  requires  the  most  care  in  discrimination. 

Chronic  bronchitis  is  not  common  except  in  old  persons  ;  its 
expectoration  is  thinner,  v/hiter,  and  not  nummular  nor  bloody  ; 
there  is  no  hectic,  although  there  may  be  emaciation  ;  and  there 
are  none  of  the  special  physical  signs  of  phthisis. 

Cancer  of  the  lung  exhibits  a  marked  dulness  of  resonance  on 
percussion  on  one  side,  with  blowing  respiration,  unless  a  bron- 
chial tube  be  obstructed,  when  there  is  no  respiratory  sound. 
There  is  severe  and  almost  constant  pain  in  the  chest.    The  pecu- 


1  Dr.  J.  G.  Richardson  calls  attention  to  the  sqwire  fracture  of  these  fragments  as  being 
distinctive. 

20 


230        DISEASES   OF   ORGANS  OF   RESPIRATION. 

liar  auscultatory  signs  of  tubercular  disease  are  absent ;  while  the 
sallow,  cachectic  aspect  of  cancer,  and  the  concurrent  existence 
of  carcinomatous  tumors  somewhere  in  the  body,  generally  make 
the  case  clear. 

In  "chronic  pleurisy,"  as  pleuritic  effusion  is  often  called,  the 
dulness  on  percussion  is  at  the  lower  part  of  the  chest ;  the  side  is 
expanded,  unless  after  the  fluid  is  absorbed  ;  respiratory  murmur 
and  vocal  vibration  are  suppressed  ;  and  the  general  symptoms, 
as  irritative  fever  and  wasting,  are  not  so  extreme. 

Bronchial  globular  dilatation  may  give  auscultatory  signs  exactly 
like  those  of  a  tubercular  cavity;  but  there  is  no  haemoptysis  nor 
emaciation,  nor  much  loss  of  health.  The  expectoration  mfiy  be 
as  copious  as  in  consumption;  but  the  matter  is  more  liquid, 
and  pus  much  more  diffused  in  it.  The  cough  is  more  constant 
than  in  phthisis. 

Abscess  of  the  lung  is  to  be  distinguished  from  phthisis  by  its 
history,  generally  following  recognized  pneumonia  ;  its  seat  mostly 
at  the  base  of  the  lung  ;  its  physical  signs  decreasing  instead  of 
increasing ;  and,  as  with  cancer,  the  affection  being  confined  alto- 
gether to  one  lung.  The  extension  of  the  signs  to  both  lungs  is 
important  in  most  cases  in  the  diagnosis  of  phthisis. 

Dr.  Walshe  states  that  caseous  infiltration  is  more  likely  to  occur 
either  at  the  base,  or  in  the  middle  portion  of  the  lung  than  is  the 
case  with  tuberculization.^ 

Syphilitic  disorder  sometimes  affects  the  lungs  and  bronchial 
tubes,  with  a  condition  almost  undistinguishable  from  ordinary 
consumption.  The  previous  existence  of  venereal  disease,  and 
periosteal  nodes  upon  the  clavicles,  with  the  slower  progress  of 
the  decline,  will  help  to  enlighten  us. 

Prognosis. — Phthisis  is  certainly  one  of  the  most  destructive 
of  diseases.  In  no  case  can  recovery  be  anticipated  ;  but  it  does 
occur,  as  every  physician  must  have  witnessed.  I  have  seen  a  num- 
ber of  such  recoveries ;  generally  from  the  incipient  stage,  but  also 
even  where  vomicae,  emaciation,  and  night-sweats  had  occurred. 
Dr.  A.  Flint  has  recorded  the  history  of  sixty-two  cases  of  resto- 
ration from  consumption.  Cruveilhier  said  of  phthisis,  long  ago, 
"Prevent  inflammation,  and  you  will  cure  your  patient."  Her- 
ard  and  Cornil  have  lately  asserted  nearly  the  same  opinion. 

Under  improved  hygiene  and  medical  treatment,  the  mortality 
from  phthisis  appears  to  be  declining.  Without  referring  to  sta- 
tistics (the  nomenclature  connected  with  which  in  past  times 
would  be  a  source  of  doubt,  as  chronic  bronchitis,  etc.,  were  once 
called  consumption),  I  am  convinced  that  fewer  people  die  of 
phthisis  now  than  thirty  years  ago,  in  Philadelphia. 

The  duration  of  phthisis  varies  greatly,  being  least,  as  a  general 
rule,  in  the  youngest  subjects.  Eighteen  months  to  two  years  is 
the  most  frequent  period.  But  in  some  instances  life  is  prolonged 
under  it  for  twenty,  thirty,  or  even  forty  years. 

Dr.  C.  T.  Williams^  found  the  average  duration  of  198  cases, 
under  favorable  circumstances  for  treatment,  over  seven  years ; 

1  Treatise  on  Diseases  of  the  Lungs,  4th  edition,  1871. 

2  Lancet,  January  21,  1871. 


PHTHISIS    PULMONAI^IS.  231 

and  of  802  still  living,  the  average  continuance  of  the  disease  was 
more  tlian  eight  years.  It  is  probable  tliat,  in  cases  not  cured,  the 
hygienic  and  therapeutic  measures  now  employed  increase  the 
length  of  life  much  beyond  what  was  possible  thirty  or  forty 
years  ago. 

In  the  United  States,  however,  the  deaths  from  phthisis  still 
constitute  about  25  per  cent,  of  the  whole  mortality  from  all 
diseases. 

Acute  phthisis,  or  galloping  consumption,  may  end  life  in  from 
six  weeks  to  three  months.  This  sometimes  follows  pneumonia. 
Its  symptoms  differ  from  those  of  ordinary  consumption  chiefly  in 
their  rate  of  progress.  Softening  of  the  tubercle  and  the  forma- 
tion of  cavities  do  not  always  occur  to  any  extent,  apnoea  being 
caused  by  extensive  diffusion  or  infiltration  of  the  tuberculous  or 
caseous  deposit  through  the  lungs. 

In  any  case  of  consumption,  the  state  of  the  general  system  is  of 
primary  import  in  prognosis.  When  the  patient  is  gaining  in 
weight  and  strength,  and  fever  and  night-sweats  diminish  or  dis- 
appear, there  is  hope,  for  a  time  at  least.  Spitting  of  blood  (when 
consumption  is  proved  to  exist  already)  does  not  increase  the  un- 
favorable aspect  of  the  case.  Rapid  emaciation,  chills,  hectic, 
swelling  of  the  feet,  and  diarrhoea  are  always  discouraging  ;  as, 
of  course,  are,  also,  all  signs  of  increase  in  the  local  pulmonic 
affection. 

Causation. — Hereditary  taint  of  constitution^  is  general ;  inde- 
pendent origination  of  phthisis  the  exception.  From  18  to  35  years 
is  the  time  of  life  most  subject  to  it ;  but  it  is  now  and  then  met 
with  even  in  children,  and  frequently  in  the  aged.  Statistics  in 
Europe  and  in  this  country  show  some  proportion  between  the 
mortality  from  consumption  and  nearness  to  the  sea-level ;  the 
lowest  lands  having  the  greatest  total  amount  of  it.  High,  dry, 
and  equable  climates  and  situations,  even  though  cold,  are  most 
exempt  from  it.  It  is  not  a  disease  of  the  Arctic  regions,  and  there 
is  more  of  it  in  Tennessee  than  in  Illinois. 

The  views  of  Oppolzer,  jS'iemeyer,  Yirchow,  and  others,  con- 
cerning the  frequent  origination  of  consumption  in  "caseous  pneu- 
monia" or  broncho-pneumonia,  or  bronchitis,  and  the  declaration 
that  tubercle  is  absent  in  a  large  number  of  cases,  even  of  fatal 
consumption,  have  received,  as  they  deserve,  critical  examination 
by  the  profession.  I  believe  it  not  safe  to  accept  so  great  a  modi- 
fication of  pathological  doctrine  as  they  involve ;  although  the 
occasional  occurrence  of  scrofulous  phthisis  without  characteristic 
tubercular  deposits  may  be  (as  indeed  it  has  long  been)  admitted. 
If  we  accept  the  opinion  of  many  pathologists,  recent  as  well  as 
older,  that  caseous  softening  is  the  customary  change  (Virchow, 
Waldenburg)  which  true  miliary  tubercle  undergoes,  it  would 
seem  quite  supposable  that  the  absence  of  true  (so-called)  tuber- 
cle in  a  number  of  cases  in  the  lungs  of  those  who  have  died  of 
phthisis  may  be  explained  by  the  process  of  softening  and  trans- 
formation having  had  time  to  be  completed. 

Among  the  predisposing  causes  of  consumption  is  congenital 

1  Even  those  who  advocate  the  new  views  (resorption,  or  infection)  of  the  uaturo 
of  consumption  mostly  admit  a  "  vulnerability  "  which  is  inherited. 


232       DISEASES   OF   ORGANS   OF   RESPIRATION. 

stenosis  (contraction)  of  the  pulmonary  artery  (Farre,  Gregory, 
Louis,  Traube,  Frerichs,  Lebert). 

Dr.  A.  Flint,^  analyzing  670  cases  of  phthisis  in  private  and 
hospital  practice,  concludes  as  follows  :  "Pneumonia  and  bron- 
chitis have  very  little  if  any  causative  influence  in  developing  this 
disease  ;  and  there  is  no  clinical  evidence  of  haemoptysis  having 
such  an  influence.  ISTor  is  there  evidence  to  sustain  the  hypothesis 
which  attributes  miliary  tuberculosis  to  absorption  of  morbid  pro- 
ducts in  different  parts  of  the  body.  The  doctrine  is  sustained 
that  pulmonary  tuberculosis  is  eminently  a  diathetic  disease  ;  i.  e., 
one  arising  from  a  constitutional  determining  agency."  Allusion 
has  been  made  in  a  previous  part  of  this  book  to  what  I  believe 
to  be  the  untenable  theory  of  the  existence  of  a  specific  virus 
(Cohnbeim,  Martin)  productive  of  tubercle.  (See  General  Path- 
ology ;  Tuberculosis. ) 

individually,  and  in  families,  all  causes  that  depress  vitality  pro- 
duce consumption  ;  but  most  of  all  impure  atmosphere.'^  Sedentary 
employments  and  exhausting  excesses,  with  foul  air,  make  large 
cities  very  productive  of  it.  In  constitutions  having  the  proclivity 
towards  it,  tuberculization  may  be  brought  on  by  any  reducing 
disease,  especially  such  as  involves  the  breathing  organs  ;  as 
measles,  bronchitis,  or  pneumonia.  Dr.  Copeland^  considers  that 
phthisis  may  be  communicated^  by  the  emanations  from  the  lungs 
and  skin  of  a  patient ;  and  hence  urges  that  consumptive  mothers 
should  not  nurse  their  infants  ;  and  that  healthy  persons  should 
not  sleep  with  consumptives.  Parks,  Budd,  and  others,  confirm 
this  opinion ;  which  was  held  also  by  Morgagni,  Laennec,  Andral, 
and  Sir  James  Clark.  Dr.  R.  Payne  Cotton,  of  the  Consumption 
Hospital,  Brompton,  England,  with  extended  opportunities  for 
observation,  denies  it.*  If  proved,  it  is  not  a  spjecific  contagion., 
but  extension  of  decay  hy  contact  with  decaying  tissue.  Drs.  W.  H. 
Webb^  and  E.  Holden,®  in  papers  upon  this  topic,  give  references 
showing  an  affirmative  opinion  in  regard  to  the  communicability 
of  phthisis  to  have  been  expressed  by  Galen,  Cullen,  Ileberden, 
Morgagni,  Laennec,  Andral,  Bright,  Addison,  Copeland,  Drake, 
Dickson,  Budd,  Walshe,  Beale,  Bowditch,  Flint,  Stille,  Da  Costa, 
and  others.  Dr.  Holden  obtained,  in  answer  to  circulars  of  in- 
quiry, two  hundred  and  fifty  replies  from  leading  physicians  in 
different  parts  of  the  United  States.  Of  these,  one  hundred  and 
twenty-six  afiirmed  their  belief  that  consumption  is  communica- 
ble. The  judgment  of  Sir  T.  Watson  is  no  doubt  well  expressed  ; 
who,  while  denying  that  phthisis  is  contagious,  would  still,  "for 
obvious  reasons,  dissuade  the  occupation  of  the  same  bed,  or 
even  the  same  sleeping  apartment,  by  two  persons,  one  of  whom 
was  known  to  labor  under  pulmonary  consumption." 

Treatment. — Hygienicmanagementis,  decidedly,  more  important 

1  New  York  Medical  Record,  1873. 

2  Dr.  MacCormac,  of  Belfast,  has  rendered  service  to  the  profession  hy  especially  en- 
forcing this.  Dr.  Bowditch,  of  Boston,  U.  S.,  and  Dr.  Buchanan,  in  England,  have  like- 
wise  shown  the  great  importance  of  dampness  of  situation  as  a  promotive  cause  of 
phthisis. 

3  On  Consumption  and  Bronchitis,  London,  1866. 
i  Brit.  Med.  Journal,  Aug.  31,  1873. 

fi  Amer.  Journal  of  Med.  Sciences,  April,  1878,  p.  426. 
6  Ihid.,  July,  1878,  p.  14.5. 


PHTHISIS    PUI.MONALIS.  233 

to  the  consumptive  than  mctlicine.     The  following  precepts  are 
well  laid  down  by  Dr.  B.  W.  llichardson  : — 

1.  A  supply  of  pure  and  fresh  air  for  respiration  is  constantly 
required  hy  the  tuberculous  patient. 

2.  Daily  exercise  in  the  open  air  is  impcrativelj^  demanded  by 
the  tuberculous  patient. 

3.  It  is  important  to  secure  for  the  patient  a  uniform,  sheltered, 
temperate,  and  mild  climate  to  live  in,  with  a  temperature  about 
00°  and  a  range  of  not  more  than  10°  or  15° ;  where,  also,  the  soil 
is  dry  and  the  drinking-water  pure  and  not  hard. 

4.  The  dress  of  the  tuberculous  patient  ought  to  be  of  such  a 
kind  as  to  equalize  and  retain  the  temperature  of  the  body. 

5.  The  hours  of  rest  should  extend  from  sunset  to  sunrise. 

G.  Indoor  or  sedentary  occupation  must  be  suspended  ;  but  out- 
door employment  in  the  fresh  air,  even  in  the  midst  of  snow,  has 
been  and  may  be  advantageous. 

7.  Cleanliness  of  l)ody  is  a  special  point  to  be  attended  to  in  the 
hygienic  treatment  of  tuberculosis. 

8.  Marriage  of  consumptive  females,  for  the  sake  of  arresting 
the  disease  by  pregnancy,  is  morally  wrong  and  physically  mis- 
chievous. 

Dr.  Hermann  Weber  asserts,  upon  experience,  that  prolonged 
residence  in  elevated  localities  is  curative  of  phthisis. 

Altogether,  the  analeptic  principle  is  now  universally  adopted 
for  the  treatment  of  consumption.  The  diet  must  be  nourishing  ; 
a  "generous"  regimen;  and  tlie  same  indication  is  to  be  followed 
in  the  employment  of  medicines. 

There  has  been  discovered,  as  yet,  no  specific  to  arrest  tubercu- 
losis. But  cod-liver  oil  and  alcohol,  and,  in  lesser  potency,  iron, 
quinine,  and  other  tonics,  in  a  certain  number  of  cases  do  mani- 
fest an  important  conservative  and  restorative  influence  ;  and 
palliation  of  symptoms,  as  pain,  cough,  loss  of  rest,  may  greatly 
help  the  comfort  of  the  patient.  My  confidence  in  the  frequent 
value  of  cod-liver  oil  is  based  chiefly  upon  observation.  Three 
individuals  in  one  family,  for  example,  under  my  care,  notwith- 
standing a  well-marked  family  tendency  (shown  by  the  previous 
death  by  phthisis  of  three  sisters,  their  mother,  and  uncle), 
recovered  from  incipient  consumption  under  the  use  of  the  oil. 
Other  cases,  much  more  commonly,  have  life  prolonged  by  it. 
Unfortunately,  however,  in  quite  a  considerable  number  of  per- 
sons the  stomach  turns  against  cod-liver  oil.  When  that  is  the 
case,  it  is  in  vain  to  urge  it.  It  may  be  taken  in  the  froth  of 
porter  or  ale,  or  after  rinsing  the  mouth  with  brandy,  which  may 
also  follow  it.  Some  dislike  it  less  when  saltecl.  Ammonia 
added  to  the  oil  lessens  its  taste  ;  but  I  have  not  tried  the  com- 
bination extensively.  Addition  of  ■walnut  (or  other)  catsup  ^  will 
disguise  its  taste  quite  effectively.  The  gelatinous  capsules 
make  it  much  less  disagreeable  to  swallow;  but  less  than  two 
or  three  table  spoonfuls  of  the  oil  daily  will  hardly  suflice.  It 
can  always  be  taken  best  in  cold  weather  [F.  30,  31,  32].  Dr.  B. 
W.  Foster,  on  theoretical  grounds,  has  proposed  the  addition  of 

1  Pharmaceutical  Journal,  18SI. 
20* 


234      DISEASES  OF  OEGANS   OF   RESPIRATION. 

etlier  to  cod-liver  oil,  to  promote  its  digestion  by  the  pancreatic 
secretion.  Dr.  Van  den  Corput,  of  Brussels'  gives,  with  asserted 
advantage,  boluses  of  cod-liver  oil  saponified  by  hydrate  of  lime. 
A  bitter  tincture,  as  of  bark  (Huxham's),  columbo,  or  gentian, 
will  lessen  the  disagreeableness  of  the  oil,  while  adding  to  its 
tonic  effect.  Carre,  Lemoine,  and  Bouchut  have  found^  cod-liver 
oil  bread  very  available,  especially  for  children.  Every  pound  of 
bread  may  contain  about  five  tablespoonfuls  of  oil,  and  six  spoon- 
fuls of  milk.     The  taste  is  said  to  be  thus  very  much  disguised. 

Alcohol,  though  variouslj'^  estimated  by  different  physicians,  is, 
in  my  view,  well  established  as  a  remedial  or  at  all  events  a  sup- 
porting agent  of  value  in  consumption.  ISTot  to  be  used  in  excess, 
nor  ever  to  produce  excitement  in  any  degree  ;  but  simply  as  a 
roborant ;  an  addition  to  the  diet  and  a  supporter  of  the  strength 
of  the  invalid.  The  dose  must,  therefore,  be  proportioned  toliis 
condition  ;  and  it  ought  usually  to  be  small. 

Whisky  is  preferred  by  many ;  but  ale,  lager  beer,  and  wine 
suit  different  patients  best.  A  little,  two  or  three  times  daily, 
will  be  much  better  than  a  full  drink  at  one  time.  I  would  always 
begin  with  very  small  quantities — say  two  or  three  teaspoonfuls 
of  whisky,  or  half  a  glass  or  even  less  of  wine,  or  half  a  tum- 
blerful of  ale  or  beer.  To  do  good,  the  stimulant  should  not 
quicken  the  pulse^  flush  the  face,  or  be  felt  to  affect  the  head.  Kept 
under  such  restrictions,  even  when  increased  to  meet  great  pros- 
tration, I  have  never  known  any  hankering  after  excess  to  be 
caused  by  it.  One  patient  of  mine,  with  phthisis,  would  some- 
times, when  temporarily  much  reduced,  take  more  than  half  a 
pint  of  whisky  daily  for  a  time ;  and  then  as  his  strength  rallied, 
would  diminish  the  amount  to  almost  none,  without  any  difficulty 
or  longing  for  more. 

"VVe  have  heard  of  advantage  accruing  from  the  "raw  beef  and 
brandy  "  treatment  for  consumption ;  but  I  am  doubtful  of  its 
possessing  any  very  special  virtue.^  When  it  can  be  done,  alcoholic 
stimulus  is  best  given  with  nourishment,  as  in  milk,  or  beaten  up 
with  a  raw  egg,  etc.  Koumiss,  a  fermented  drink,  made  from 
mare's  or  cow's  milk,  is  a  popular  remedy  of  the  Tartars,  adopted 
to  some  extent  by  the  Russian  physicians. 

Beef-tea,  as  a  concentrated  nutrient,  is  very  useful  when 
digestive  power  is  low,  at  any  stage  of  phthisis.  One  lady  under 
my  care,  who,  with  tussieula,  heemoptysis,  and  emaciation,  had 
greatly  the  appearance  of  incipient  consumption,  and  who  could 
not  retain  cod-liver  oil  upon  her  stomach  without  loss  of  appetite, 
was  put  upon  the  daily  use  of  a  pint  of  strong  beef-tea,*  for 
several  weeks  together,  with  no  medicine  but  a  mild  expectorant. 
She  recovered,  and  has  since  married  and  become  a  mother. 

1  Med.  Times  and  Gazette,  Nov.  26,  1870.  2  Bulletin  de  Therapeut.,  1873. 

3  The  possibility  of  parasites  being  taken  into  the  body  with  raw  beef  is  exemplified 
by  a  case  reported  by  Dr.  Leidy,  in  which  taenia  mediocaneliata  was  evidently  thus 
introduced. 

4  The  mode  of  preparation  of  beef-tea  is  not  unimportant.  I  prefer  the  following: 
Cut  up  a  pound  of  good  lean  beef  into  small  pieces,  pour  upon  it  half  a  pint  or  a  piut 
of  cold  water,  and  let  it  stand  two  hours  beside  the  fire.  Then  boil  it  20  minutes  or 
half  an  hour.  Take  otf  all  the  scum  and  oil-drops,  carefully ;  but  do  not  filter  or  strain 
it  unless  through  a  coarse  sieve.  It  should  have  a  rich  brown  color;  and  with  salt  is 
agreeable  to  the  taste. 


PHTHISIS    PULMONALIS.  235 

The  phosphates  and  hypophosphitos  of  calcium,  etc.,  have  been 
suHicieiitly  ti-icd  to  prove  tlieir  inferiority  to  cod-liver  oil.  My 
own  experience  with  them,  in  the  wards  of  the  Episcopal  Hos- 
pital in  this  city,  as  well' as  in  private  practice,  has  been  dis- 
couragin<,r ;  and  I  believe  the  best  phosphate  for  analeptic  use  to 
be  phosphate  of  iron.  Dr.  Henry  lilanc  {Lmuxt,  June  13,  1874) 
insists  on  the  value  of  the  phosphate  of  calcium,  given  at  the 
same  time  with  the  juice  of  raw  meat ;  the  phosphate  being 
always  taken  at  meal  times.  Chlorate  of  potassium  has,  I  think, 
failed  under  fair  trial,  although  a  few  (as  Dr.  E.  J.  Fountain,  of 
Iowa)  still  confide  in  it.  Glycerin  will  not  take  the  place  of  cod- 
liver  oil ;  nor  has  any  oil  been  shown  to  be  capable  of  doing  so. 
Ilrrard  and  Sankey  have  used  arsenic  in  small  doses  ;  Dr.  Mou- 
tard-Martin'  considers  it  a  valuable  remedy  in  phthisis.  Dr.  \V. 
M.  Logan,  of  Cincinnati,  reports'*  the  recovery  of  ten  out  of 
twenty-four  cases,  treated  with  thirty  or  forty  drop  doses  of  nitric 
acid  (after  meals)  along  with  tincture  of  chloride  of  iron  ;  besides 
hygienic  measures,  and  in  some  cases,cod-liver  oil.  Drs.  Blacque, 
of  ^Paris,  and  Griffith  and  Milton'  of  Bradford,  Pa.,  assert  the 
cure  of  a  number  of  cases  under  the  use  of  crude  j)etroleum  (dose 
3  or  4  drops).  Dr.  Inman,  of  Liverpool,  and  others,  recommend 
frequent  wimction  witli  oil. 

In  1879,  henzoate  of  sodium  was  urged,  especially  in  Germany 
(Kroczak,  Klebs),  as  a  valuable  medicine  in  phthisis,  when  used 
by  inhalation.  Conflicting  evidence,  however,  soon  threw  its 
usefulness  into  great  doubt ;  as  may  be  expected  with  regard  to 
any  special  "remedy  "  for  such  a  disease. 

Maltine,  or  Malt  Extract,  is  largely  used  in  some  German  hos- 
pitals, instead  of  cod-liver  oil ;  and  a  number  of  American  prac- 
titioners place  a  high  value  on  it.  It  remains,  I  think,  to  be 
proved  that  it  can  compare  favorably  with  cod-liver  oil  as  a 
recuperant. 

Where  expectoration  is  copious  and  fluid,  I  believe  creasote, 
internally  given,  to  be  a  useful  medicine.  Bouchard  and  Gim- 
bert*  found  it  to  exert  an  evidently  beneficial  influence  in  54 
cases  out  of  93.  It  increases  the  appetite,  and  probably  tends 
to  retard  the  softening  process  in  the  lungs.  It  may  be  given  in 
cod-liver  oil, — with  an  aromatic  or  bitter  tonic,  as  comp.  tinct.  of 
gentian. 

Iron,  especially  the  iodide  [F.  33]  and  the  tincture  of  the  chlo- 
ride, are  frequently  suitable  ;  and  so  may  be  quinine,  nux  vomica 
[F.  34],  or  the  simple  bitter  tonics.  But  the  patient  must  not  be 
worried  and  disgusted  with  much  medicine,*  whatever  depresses 
ai^petite  is  likely  to  do  more  harm  than  good. 

For  this  reason,  expectorants  require  discretion  in  their  use. 
Those  of  a  nauseous  kind  must  be  very  sparingly  prescribed  in 
phthisis.  The  syrup  or  fluid  extract  of  wild  cherry  [F.  35,  36] 
is  one  of  the   most  suitable.     Squills  will  do  when  loosening 

1  Bulletin  General  Therapeutique,  Nov.  15,  1868. 

2  Consumption  :  its  Pathology  and  Treatment;  Philadelphia,  1871. 

3  N.  Y.  Med.  Kecord,  July  2, 1881,  Consumption  is  said  to  be  rare  in  the  oil  region  of 
Pennsylvania. 

^  Gazette  Hebdomadaire,  Nos.  31  and  33, 1877. 


236        DISEASES   OF  ORGANS   OF   RESPIRATION. 

effect  is  particularly  required.  Ipecac  and  tartar  emetic  are  too 
depressing  to  the  stomach  for  the  consumptive.  Sometimes, 
at  a  late  stage,  carbonate  of  ammonium  will  be  useful  as  a 
stimulant. 

Anodynes  and  calmatives  are  almost  always  wanted  as  the  case 
advances,  to  soothe  the  wearisome  cough,  and  to  give  rest  at 
night.  Lactucarium,  hyoscyamus,  hydrate  of  chloral,  and  finally 
opium,  or  morphia,  in  some  form,  will  be  important  sources  of 
comfort  to  the  patient,  and  may  economize  his  strength.  Mazza 
recommends  cyanide  of  potassium  in  small  doses. 

Hsemoptysis,  when  not  large  in  amount,  requires  only  quiet- 
ness, for  the  time,  with  little  or  no  special  medical  treatment. 
Should  much  blood  be  raised,  the  patient  ought  to  be  kept  in  bed, 
with  the  shoulders  somewhat  raised  ;  and  only  iced  milk  and  beef 
essence,  or  beef-tea,  should  be  given  for  food.  Gallic  acid,  in  ten 
grain  doses  every  two  or  three  hours,  will  then  be  an  available 
styptic  medicine.  Ergot,  however,  is  preferred  by  many  (Anstie). 
The  poiDular  remedy  of  holding  salt  in  the  mouth  may  be  of 
some  temporary  use  in  hemorrhage.  Slowly  melting  and  swal- 
lowing ice  will  probably  do  more  good.  If  nervous  disquietude 
exist,  it  may  be  allayed  by  an  opiate  at  night. 

The  colliquative  sweats  seldom  demand  treatment,  they  being 
the  result  rather  than  the  cause  of  debility.  Oxide  of  zinc  has 
been  much  used  for  them.  Belladonna  is  found  (Frantzel)  ^  to 
reduce  the  amount  of  perspiration.  Atropia  (S.  Ringer)  prob- 
ably has  the  greatest  control  over  it  of  all  drugs.  Ablution  with 
brandy  or  whisky  and  alum  may  be  practised  if  sweating  is  very 
excessive.  Diarrhoea  may  require  to  be  held  in  check,  by  simi^le 
astringents  and  opiates,  especially  in  enemata. 

If  pleurisy  or  peritonitis  supervene  as  a  complication,  the  local 
inflammation  must  be  treated  in  view  of  the  general  condition. 
Depletion  is  out  of  the  question  at  an  advanced  stage.  Dry 
cups,  small  blisters,  and  opium  are  all  that  we  can  use  in  the 
treatment.  For  the  variable  pains  in  the  chest  in  the  course 
of  the  disease,  mild  or  moderate  counter-irritation,  by  warming 
or  belladonna  plasters,  tincture  of  iodine,  or  croton  oil,  may  be 
used. 

It  is  not,  however,  to  be  said  that  the  name  or  character  of 
phthisis  should  in  all  cases  rule  out  local  depletion  in  the  incipient 
stage.  In  one  of  three  cases  in  a  family  (already  alluded  to) 
who  recovered,  notwithstanding  a  strong  inherited  tendency  to 
consumption,  from  a  condition  threatening  it,  a  great  relief  and 
improvement  followed  the  early  application  of  two  dozen  leeches 
to  the  side ;  it  was  (to  borrow  an  expression  of  Dr.  Condie's)  at 
the  time  an  acute  tuberculous  pneumonia.  Yet  such  cases  are 
exceptional.  The  pervading  indications  in  phthisis  are  economy 
and  recuperation.  Niemeyer's  suggestion  that  the  identification 
of  phthisis  with  caseous  pneumonia  should  lead  us  to  put  all  con- 
sumptives, in  the  early  febrile  stage,  to  bed,  and  bleed  or  cup 
them,  could  not  be  approved  as  a  rule  of  practice,  even  if  his 
pathological  views  should  be  accepted. 

1  Virchow's  Arehiv,  Ixviii.  1. 


PHTHISIS    PULMONALIS.  287 

Inhaldtinn  has  often  been  tried  in  phthisis.  Not  onnmorating 
agents  which  liave  siuninarily  failed,  I  believe  that  tlie  best  hope 
attaches,  in  this  way,  to  inhalation  of  the  vapor  of  on^asote  or  of 
carbolic  acid.  These  agents-are  styptic,  and  by  coagulating  albu- 
men and  all)uniinoid  material  maybe  expected  to  aid  in  arresting 
the  softening  and  destructive  process  in  the  lung.  At  least,  we 
might  hope  that  this  would  (Cursclimann  has  found  it  to  do  so) 
lessen  excessive  and  exhausting  expectoration.  Dr.  Marcet' 
I'cports  favorably  of  the  use,  by  inhalation,  of  carbolic  acid,  one 
or  two  grains  to  the  ounce  of  water.  Dr.  G.  II.  Ma(;kenzie''  has 
recorded  excellent  eflects  produced  in  a  marked  case  by  the  con- 
tinuoiis  inhalation  of  creasote ;  great  diminution  of  expectora- 
tion resulting,  with  abolition  of  the  night-sweats,  and  improve- 
ment in  appetite  and  strength.  Dr.  Cheron'*  asserts  the  value, 
especially  in  slowly  progressing  cases,  of  inhalation  of  the  vapors 
of  oxygenated  essences ;  as  that  of  the  laums  camphnrm^  cedar, 
chamomile  and  eucalyptus.  Oxygen  is  given  by  inhalation  in  the 
practice  of  some  physicians ;  and  so  have  been  conqjressed  air 
and  very  dilute  nitrous  oxide  gas.  I  have  no  positive  knowledge 
of  their  results. 

Transfusion  of  lamh''s  Wood  has  been  tried  in  Germany,  with 
doubtful  advantage.'^  Assistant  Surgeon  Wood,  U.  S.  A.,  has 
reported  a  case  of  recovery  following  transfusion  of  four  ounces 
of  human  blood.  Injection  of  a  pulmonary  cavity  with  alterative 
solutions  (as  tincture  of  iodine,  carbolic  acid,  permanganate  of 
potassium)  has  been  proved,  by  Berkart,  Koch,  Mosler,  Thomp- 
son, W.  Pepper,^  and  others,  to  be  safe,  if  a  hollow  needle 
(Dieulafoy's)  or  capillary  trocar  and  canula  be  used;  and,  in 
some  instances,  the  effects  have  appeared  to  be  beneficial.  Jn 
cases  manifestly  progressing  towards  death,  such  a  practice  seems 
worthy  of  trial ;  with  the  hope  of  promoting  the  cicatrization 
of  cavities.  Dr.  J.  H.  Hutchinson  has  shown  {Phila.  Med.  Times, 
Ma}'^  30,  1874)  that  even  Hippocrates  recommeuded  puncture  of 
the  chest  in  phthisis ;  the  idea  of  it  being  revived  by  Baglivi 
(1723)  and  Ramadge  (1836).  Hastings  and  Stork  practised  it 
about  1845.  Prof.  J.  H.  Bennett  {Reynolds'' s  System  of  Medicine, 
article.  Phthisis)  asserts  that,  as  might  have  been  expected 
from  the  nature  of  the  disease,  such  measures  have  uniformly 
and  totally  failed. 

Change  of  climate  is  often  proposed  for  the  benefit  of  the  con- 
sumptive. In  an  early,  or  middle,  or  even  a  stationary  advanced 
stage,  it  may  be  of  important  advantage.  When  to  forbid,  or 
advise  it,  may  be  a  very  delicate  question.  More  will  depend 
upon  the  rate  of  progress  than  upon  the  period  of  the  case.  But 
the  patient  must  have  strength  enough  to  travel,  and  must  be 
not  too  dependent  upon  his  home  comforts,  or  he  may  be  made 
worse  instead  of  better.  It  is  cruelty  to  banish  one  who  is 
already  on  the  verge  of  the  grave  to  die  in  a  strange  place 
among  strangers.     Yet  I  have  known  life  to  be  prolonged  from 


1  Practitioner,  November,  18G8.  2  Lancet,  May  14,  1881. 

3  Gaz<tto  Hebdoni.,  No.  51,  1872.  *  See  Transfusion,  Part  I, 

6  Pbilada.  M  dical  Times,  March  14, 1874. 


238      DISEASES  OF   ORGANS   OF   RESPIRATION. 

year  to  year,  in  those  who  were  natives  of  a  Northern  city,  by 
spending  the  winter  South. 

In  selecting  a  climate  for  the  invalid,  equability  and  dryness 
are,  unless  at  a  late  stage,  more  important  than  warmth.  That 
climate  which  will  allow  the  patient  the  greatest  number  of  days 
out  of  doors,  will  be  the  best.  Minnesota,  and  other  places  near 
Lake  Superior,  agree  extremely  well  with  some,  in  the  early,  but 
not  so  well  in  the  later  stages  of  the  disease.  Of  southern  locali- 
ties, Florida  (best  of  all  its  central  pine-lands)  presents  an  espe- 
cially equable,  almost  maritime,  climate.  Cuba  is  often  resorted 
to,  A  sea  voyage  (if  not  subject  to  exhausting  sea-sickness)  may 
do  good  at  an  early  stage.  Across  the  ocean,  consumj)tives  resort 
to  the  South  of  France,  particularly  to  Pau  or  Biarritz ;  or  to 
Mentone,  or  Malaga,  or  Malta;  or  Italy— especially  Ischia  or 
Capri,  Sorrento  or  Palermo ; — Madeira,  and  Algeria,  the  year 
round,  and  Egypt  in  the  winter  only,  are  favorite  climes.  For 
the  winter,  nothing  could  excel  in  salubrity  the  atmosphere  of 
the  Upper  Nile. 

Our  own  country  affords  all  the  requisites  for  the  migration  of 
an  invalid,  to  escape  the  inclemencies  of  every  season,  if  he  can 
vibrate  between  Newport,  E.  I.,  in  the  summer,  and  St.  Augus- 
tine or  the  interior  of  Florida  for  the  winter ;  or  else  between 
Minnesota  in  the  summer,  and  Southern  California  (Santa  Bar- 
bara, San  Diego)  for  the  colder  half  of  the  year.  The  locality 
most  recommended  by  the  State  Board  of  Health  of  California 
(1880)  for  a  Hospital  for  consumptives,  is  Atlas  Peak,  in  Napa 
county,  on  the  ridge  of  the  Coast  Range  mountains.  Colorado, 
also,  is  now  much  resorted  to  ;  but  it  does  not  agree  with  all 
patients.  There  is  no  one  climate  which  will  do  so.  With  those 
who  can  travel,  individual  experience  is  a  better  ground  of 
choice  than  any  climatic  theory  as  yet  established. 

PMMsis  in  Early  Life. — ^Dr.  C.  West  ^  names  the  following  as 
characteristics  of  consumption  in  children,  among  whom,  how- 
ever, it  is  certainly  rare : — 

1st.  The  frequent  latency  of  the  thoracic  symptoms  during  the 
early  stages. 

2d.  The  almost  invariable  absence  of  haemoptysis  at  the  com- 
mencement of  the  disease,  and  its  comparatively  rare  occurrence 
during  its  subsequent  progress. 

3d.  The  partial  or  complete  absence  of  expectoration. 

4th.  The  rarity  of  profuse  general  sweats  ;  and  the  ill-marked 
character  of  the  hectic  symptoms. 

5th.  The  frequency  with  which  death  takes  jplace  from  inter- 
current bronchitis  or  pneumonia. 

The  same  excellent  authority  designates  the  following  peculi- 
arities in  the  auscultatory  phenomena  of  consumption  in  the 
child  :— 

1st.  The  smaller  value  of  coarse  respiration,  prolonged  expira- 
tion, and  interrupted  breathing,  owing  to  their  general  diffusion 
over  the  chest,  and  to  their  occasional  existence  independently 
of  phthisis.^ 

1  Diseases  of  Children,  p.  404. 

2  The  occurrence  of  harsh  respiratory  sound  as  an  initial  sign  in  pneumonia  of  chil- 
dren is  well  established. 


PERICARDITIS.  239 

2(1.  The  greater  difficulty  of  distinguishing  chronic  bronchitis, 
in  tho  (.•hiki,  from  phthisis. 

3d.  The  loss  of  that  information  which  the  phenomena  of  the 
voice  furnish  in  tlio  case  of  the  adult. 

4th.  The  smaller  value  of  inequality  of  breathing  in  the  two 
lungs. 

5th.  The  difficulty  of  detecting  minute  variations  in  the  reso- 
nance upon  percussion. 

0th.  The  frequent  existence  of  dulness  in  the  interscapular 
region,  with  moderate  resonance  and  tolerably  good  respiration 
in  the  upper  part  of  the  chest — characteristic  of  enlargement  of 
the  bronchial  glands. 

The  extremely  common  occurrence  in  young  children  of  "  case- 
ous "  local  affections,  of  the  glands,  etc.,  and  the  much  later 
period  at  which  tuberculization  of  the  lungs  usually  begins, 
afford  together  a  strong  argument  against  the  theory  (Buhl, 
Niemcyer)  of  the  "resorptive"  origin  of  tubercular  phthisis; 
otherwise,  at  least,  than  in  quite  exceptional  instances. 

AFFECTrOI^'S  OF  THE  ORGANS  OF  CIECULATIOK. 
PERICARDITIS. 

Definition. — Inflammation  of  the  covering  membrane  of  the 
heart. 

Varieties. — Simple  or  idiopathic,  and  rheumatic  pericarditis. 
The  latter  is  very  much  the  more  common.  Degrees  of  violence 
in  the  attack  also  cause  variations,  from  the  mildest  and  almost 
latent  cases,  through  those  of  open  and  active  severity,  to  those 
attended  by  rapid  effusion  and  prostration. 

Symptoms. — Fever  ;  pain  (occasionally  absent)  at  and  radiating 
from  the  heart  ;  tenderness  on  pressure  in  the  cardiac  region  ; 
accelerated,  irregular,  or  oppressed,  rapid  and  feeble  pulse  ; 
anxiety  or  delirium  ;  nausea  and  vomiting  in  some  cases  ;  short 
hacking  cough  ;  towards  the  end,  coldness  and  pallor  or  lividity, 
oedema  of  the  face  and  extremities,  loss  of  pulse. 

Stages. — 1st,  Acute  inflammation ;  2d,  Adhesion  ;  3d,  Effusion. 

Physical  Signs. — Before  adhesion  or  effusion,  usually,  exag- 
geration of  the  heart's  impulse.  Then,  pericardial  friction- 
sounds  (to  and  fro)  ;  the  vibration  accompanying  which  is  some- 
times felt  by  the  hand.  After  effusion,  dulness  on  percussion, 
with  muffling  of  the  heart's  sounds  to  the  ear  on  auscultation. 
The  friction-sounds  disappear  during  this  period,  sometimes  to 
return  as  the  effusion  is  absorbed. 

Morbid  Anatomy. — In  the  first  stage,  there  is  a  rose-redness 
of  the  pericardium,  diffused,  punctated,  or  in  patches.  Then, 
deposits  of  coagulable  lymph,  white  and  opaque,  sometimes 
causing  local  or  general  adhesion  of  the  two  layers  of  serous 
membrane.  In  most  fatal  cases,  effused  serum  is  found  in  the 
sac,  in  quantity  varying  from  ounces  to  pints.  Great  quantities 
of  it  may  weigh  down  the  diaphragm  below  it.  Purulent  exuda- 
tion is  sometimes  met  with.  In  scorbutic  cases,  it  may  be  hem- 
orrhagic. Tlie  muscular  tissue  of  the  heart  is  found  to  be  less 
coherent  than  usual. 


240       DISEASES    OF    ORGANS    OF   CIRCULATION, 


Diagnosis. — From  endocarditis  and  from  pleurisy  it  is  sometimes 
not  easy  to  distinguish  pericarditis.  The  symptoms  of  the  latter 
and  those  of  endocarditis  are  the  same  ;  and  the  friction-sounds 
may  occur  in  botli.  The  heart's  impulse  is  more  apt  to  be 
sustained  in  strength  in  endocarditis  ;  and  in  the  latter,  no 
dulness  on  percussion  occurs,  nor  are  the  heart-sounds  muffled 
at  any  stage ;  while  valvular  murmurs  follow  endo-  and  not  peri- 
carditis. 

Friction-sounds  which  are  outside  of  the  heart  (pericardial) 
have  a  nearer  character  to  the  ear  than  endocardial  sounds  ;  they 
are  more  narrowly  limited,  not  passing  along  the  vessels  ;  they 
do  not  keep  exact  time  with  the  cardiac  sounds,  and  may  vary 
from  day  to  day  ;  and  sometimes  the  vibration  maybe  felt  exter- 
nally. 

Pleurisy  causes  friction-sounds  and  afterwards  dulness  on 
percussion.  But  the  former  sounds  are  more  diffused,  are  gen- 
erally single,  not  "to  and  fro"  or  double;  and  the  dulness  ex- 
tends further  over  and  around  the  side.  Latent  pericarditis 
may  possibly,  from  some  symptoms,  be  taken  for  inflammation 
of  the  brain,  or  of  the  stomach.  Physical  exploration  should 
prevent  such  errors. 

Prognosis.^ — There  is  great  danger  to  life  in  pericarditis  ;  and  its 
course  is  sometimes  terminated  by  death  in  a  few  days.    In  other 

cases    resolution    may    take 
■^^^-  ^''-  place  promptly  ;    but   more 

often  the  heart  is  clogged  for 
a  considerable  time  (weeks 
or  months)  with  effusion,  or 
a  more  protracted  interfer- 
ence occurs  from  adhesion  of 
the  pericardial  surfaces.  The 
latter  is  sometimes  shown  by 
a  dimpling,  or  sinking  in, 
with  each  beat  of  the  heart, 
of  the  intercostal  spaces 
above  and  below  it. 

Causation.  —  The  process 
of  rheumatic  fever  is  far 
the  most  common  cause  of 
pericardial  inflammation,  as 
it  is  of  endocarditis  also. 
Gout  is  accused  of  the  same 
thing ;  but  with  much  less 
frequency,  or  indeed,  clear- 
ness of  proof.  Bright's  dis- 
ease of  the  kidney  is  occasionally  associated  with  it. 

Treatment. — In  active  cases,  and  good  subjects,  one  early  and 
moderate  bleeding  from  the  arm  will  be  proper.  Afterwards,  in 
some,  and  instead  with  feebler  patients,  when  fever  is  high  and 
pain  intense,  leeches  over  the  cardiac  region  may  be  used.  A 
brisk  saline  cathartic,  as  Epsom  or  Rochelle  salts,  or  citrate  of 
magnesium,  should  commence  the  medication.  Calomel,  trusted 
stil'f  by  some  and  condemned  by  others,  may  be  confined  to  open 


Pericarditis,  with  Effused  Lymph. 


PERICARDITIS.  241 

sthenic  cases,  in  previously.good  constitutions.  In  such,  I  would 
give  half  a  grain  of  calomel,  with  half  a  grain  to  a  grain  of  opium, 
thrice  daily  for  three  or  four  days.  Veratruin  vii-ide,  in  small 
doses,  is  preferred  by  some  practitioners  of  experience  ;  aconite, 
by  others. 

Where  the  rheumatic  diathesis  is  marked,  salicylic  acid  or 
alkalies  [F.  37]  will  be  indicated.  Carbonate  or  bicarbonate  of 
potassium,  or  bicarbonate  of  sodium  may  be  given  in  scruple  or 
half-scruple  doses,  with  as  much  of  Rochelle  salts,  three  or  four 
times  a  day.  A  blister  over  the  heart,  as  the  fever  lowers,  will 
often  have  a  very  good  eflect.  If  effusion  occurs,  blistering  may 
be  repeated.  Should  no  opiate  be  given  through  the  day,  Dover's 
powder  or  morphia  may  be  prescribed  at  night. 

For  the  stage  of  effusion,  or  "chronic  pericarditis,"  the  usual 
treatment  consists  of  diuretics  [F.  38,  39,  40],  as  squills,  juniper, 
sp.  ffith.  nit.,  etc.,  varied  and  continued  until  absorption  occurs. 
Tonics  will  often  much  promote  the  same  end. 

When  the  effusion  threatens  life  by  interfering  with  the  heart's 
action,  tapping  the  pericardium  may  be  a  justifiable  operation. 
Romero,  of  Barcelona  (about  1819),  first  ventured  upon  this. 
The  first  paracentesis  pericardii  in  America  was  successfully  per- 
formed by  Dr.  J.  H.  Warren,  in  1852.  Dr.  Staples,  of  Dubuque, 
Iowa,  and  Dr.  W.  Pepper,  of  Philadelphia,  both  operated  with 
successful  results  in  1877. 

Hindenlang^  and  Roberts'*  collected,  in  1879,  accounts  of  sixty 
instances  of  this  operation,  in  which  there  were  twenty-four 
recoveries  and  thirty-six  deaths.  Trousseau,  Roger,  Allbutt, 
Villeneuve,  Kussmaul,  J.  C.  Warren,  Porcher,  and  Comegys  Paul 
have  been  among  the  operators.  Dieulafoy's  aspirator  is  gener- 
ally preferred  ;  using  of  choice  a  moderately  large  needle.  The 
common  hypodermic  syringe  has  been  found  to  answer  for  the 
purpose.  The  best  point  for  puncture  is  in  the  fifth  intercostal 
space,  halfway  between  the  left  nipple  and  the  left  edge  of  the 
sternum,  avoiding  the  internal  mammary  artery. 

Much  care  is  necessary,  of  course,  in  diagnosis,  before  deciding 
upon  such  a  procedure.  A  greatly  dilated  heart  has  once,  at 
least,  been  punctured  by  mistake  for  a  distended  pericardium. 
This  should  be  guarded  against  by  acquaintance  with  the  symp- 
tomatic history  of  the  case  ;  and  by  noting  the  fact,  that  in  dila- 
tation of  the  heart,  the  apex  beat  is  always  at  the  lowest  point 
of  dulness,  while  in  excessive  pericardial  effusion  the  apex  is 
gradually  displaced  upwards,  until  at  last  it  is  almost  or  quite 
lost.  Other  diagnostic  signs  of  distended  pericardium  are  (Pep- 
per)^  "Prominence  of  the  proecordial  region;  enlarged  triangle 
of  dulness,  with  its  base  below  ;  very  distant  and  feeble  heart- 
sounds  ;  displacement  of  the  anterior  border  of  the  lungs  ;  and 
extreme  disturbance  of  circulation  and  respiration." 


1  Freiburger  Dissertation,  Deutsches  Archiv  fiir  Klin.  Bfed.,  Oct.  23, 1879. 

2  Paracentesis  of  tlie  Pericardium,  by  Dr.  ,T.  B.  Koberts.  Philadelphia,  1879.  By  the 
end  of  1880,  this  operation  had  been  performed  thirteen  times  in  America,  with  six 
recoveries. 

3  Clinical  Lecture  on  Paracentesis  of  the  Pericardium;  Med.  News  and  Library 
March,  1878. 

21  Q 


242       DISEASES  OF    ORGANS    OF    CIRCULATION. 

A  rapidly  distressing  case  of  pericarditis,  with  cold,  blue  skin 
and  feeble,  irregular  pulse,  will  require  a  supporting  or  stim- 
ulating treatment  from  the  first ;  with  dry  cups  and  blisters 
instead  of  local  or  general  bleeding  ;  and  quinine,  ammonia,  and 
whisky  instead  of  sodorifics  or  laxatives. 

Myocarditis  is  inflammation  of  the  muscular  substance  of  the 
heart.  It  can  hardly  be  said  to  have  other  than  a  nominal  exist- 
ence. Some  writers  consider  the  "white  spot,"  found  upon  the 
surface  of  the  heart  occasionally,  in  soldiers  and  others,  to  be 
the  result  of  a  low  form  of  muscular  inflammation. 

Gangrene  of  the  heart  is  said  to  have  been  clearly  proved  in 
one  or  two  instances.^ 

Pneumopericardium. — This  (distension  of  the  pericardial  sac 
with  air)  is  a  rare  affection.  It  may  result  from  a  penetrating  or 
punctured  wound  ;  from  ulcerative  or  suppurative  perforation  of 
the  pericardium  from  the  lung  or  oesophagus  ;  or  (possibly)  from 
the  formation  of  gas  by  ichorous  decomposition  of  purulent  exu- 
dation.    Of  these,  the  traumatic  origin  is  the  most  frequent. 

Signs  of  pneumopericardium  are,  ti/mpanitic  resonance  on  per- 
cussion over  the  cardiac  region  ;  metallic  and  distant  character 
of  the  heart-sounds  ;  bubbling,  gurgling  or  splashing  sounds  also 
heard  in  auscultation  over  the  heart. 

H.  Miiller,'-  of  Zurich,  collected  the  history  of  twenty-eight  cases 
of  this  affection,  half  of  which  were  of  traumatic  origin.  Nine  of 
these  cases  terminated  in  recovery. 

ENDOCARDITIS. 

Definition. — Inflammation  of  the  lining  membrane  of  the  heart. 

Symptoms  and  Physical  Signs ;  Diagnosis ;  Treatment.— These 
have  been  suflficiently  stated  in  the  account  just  given  of  pericar- 
ditis, and  need  not  be  repeated.  Like  that  disease,  it  is  most  often 
of  rheumatic  origin ;  but  may  occur  in  Bright's  disease  or  in  pyae- 
mia. Dr.  Peacock  and  others  assert  the  opinion  tbat  endocarditis 
occurs  most  frequently  in  cases  of  rheumatism  with  severe  articu- 
lar symptoms ;  while  pericarditis  is  somewhat  more  common  in 
those  in  which  the  joints  are  more  slightly  affected.  This  remains 
doubtful. 

Valvular  derangement  and  its  signs  give  great  interest  to  endo- 
carditis and  its  resulting  changes.  Mostly  it  is  the  left  side  of  the 
heart  that  is  chiefly  affected.  The  simplest  and  most  common 
sign  of  this  is  a  blowing  sound  heard  on  auscultation.  But  a  bel- 
lows-murmur is  heard  also  in  cases  of  antemia,  and  a  blowing 
sound  occurs  not  rarely  in  fevers  ;  or  it  may  belong  to  an  organic 
heart-affection  of  long  standing.  This  last  fact  should  be  ascer- 
tained by  the  history  of  the  patient,  as  well  as  by  the  aid  of  symp- 
toms ;  but  an  old  murmur  is  generally  rougher  and  more  fixed  in 
its  seat.  It  is  possible^  thoug'h  very  rare^  for  endocardial  inflam- 
mation to  be  located  so  far  from  the  valves  as  to  cause  no  blowing 
sound. 


1  Cincinnati  Med.  Repertory,  May,  1868. 

2  Deutsches  Archiv  fur  Klin.  Mediciu,  Bd.  xxiv.,  Heft  2,  1879. 


ENDOCARDITIS.  243 

Clots  occasionally  form  in  the  heart,  in  endocarditis  (as  well  as 
in  some  other  diseases  attended  h}-  jirostration),  obstructiny  the 
circulation  even  to  a  fatal  extent.  Although  most  clots  are  post- 
mortem in  origin,  there  is  no  doubt  that  sometimes  firm  fibrinous 
masses  do  occlude  the  valves  for  some  time  before  death.  The 
symptoms  and  sii^ns  produced  are,  blueness  and  coldness  of  the 
skin,  indistinctness  of  the  heart-sounds,  feebleness  and  irregularity 
of  the  pulse,  nausea  and  vomiting,  anxiety  of  expression,  and 
fain  tine. 

Much  more  often,  vegetation  or  filmnous  deposits  of  exudation 
on  the  valves  of  the  heart  are  carried  in  fragments  therefrom  l)y 
the  blood  from  the  arteries.  Being  arrested,  as  in  a  vessel  of  the 
brain  or  of  a  limb,  etc.,  the  condition  of  obstruction  designated  as 
emhoUsm  results ;  vidiieh  will  receive  attention  in  another  part  of 
this  book.  Old  valvular  vegetations,  as  well  as  the  recent  ones  of 
endocarditis,  may  give  rise  to  emboli ;  which  may,  also,  arise  from 
coagulation  in  a  vein,  or  thrombosis. 

Ulcerative  endocarditis  is  the  term  applied  when  disintegration 
of  the  lining  membrane  of  the  heart  occurs  ;  minute  fragments 
of  detached  exudation  passing  into  the  circulation  and  obstructing 
the  small  arteries,  especially  of  the  kidneys,  liver  or  spleen.  The 
most  frequent  seats  of  this  sort  of  change  are  the  aortic  and  mitral 
valves.  The  right  side  of  the  heart  is  seldom  involved  ;  when  it 
is  so,  abscess  of  the  lung  is  apt  also  to  occur. 

Rheumatic  inflammation  of  the  endocardium  may,  exception- 
ally, assume  this  form  ;  especially  in  its  later  stages.  Sometimes 
ulcerative  endocarditis  follows  injuries  or  inflammations  of  the 
uterus,  bones, etc.,  in  a  manner  which  has  caused  the  appellation 
septic  to  be  applied  to  it.  In  other  cases  no  such  origin  can  be 
ascertained.  Opinions  concerning  it  have  led  to  the  employ- 
ment of  such  terms  in  regard  to  it  as  arterial  pyixmia  (Wilkes  i, 
diphtheritic  endocarditis,  mycosis  endocardii,  and  infectious  endo- 
carditis (Jaccoud,  Klebs).  These  last  expressions  have  been 
suggested  by  the  observation  of  microscojjic  groicths  (micrococci, 
bacteria)  after  death  upon  the  valves  of  the  heart  in  some 
cases.  So  far  as  the  evidence  has  yet  gone,  however,  these 
minute  organisms  appear  to  be  rather  concomitants  than  causes 
of  the  disease. 

Practically,  ulcerative  endocarditis  is  chiefly  interesting  as  the 
source  of  multip)lc  embolism.  (See  Ernholism.)  The  symptoms  of 
this  condition  usually  resemble  those  of  pjfemia,  and  sometimes 
(Bristowe)  simulate  closely  intermittent  fever.  The  movement 
of  the  attack  is,  however,  slower  than  that  of  pypemia,  and  its 
progress  is  more  grave  and  intractable  than  that  of  ague.  There 
are  chills,  followed  by  paroxysms  of  fever,  with  nausea,  diarrhoea, 
enlargement  and  tenderness  of  the  spleen,  jaundice,  albuminuria, 
delirium ;  in  severe  cases,  coma,  and  death  commonly  in  two  or 
three  weeks.  Occasionally,  a  case  may  linger  on  for  a  few  mouths. 
Treatment  of  such  a  malady  can  be  palliative  only,  according  to  the 
symptoms,  with  measures  adapted  to  promote  and  economize  the 
patient's  strength.  Xo  doubt  slight  cases  of  it  often  occur,  and 
end  in  recovery  ;  their  nature  being  thus  overlooked  or  not  ascer- 
tained. 


244      DISEASES   OF   ORGANS    OP   CIRCULATION. 


Fig.  88. 


Endocarditis  produces  valvular  derangement  in  the  mitral  valve 
most  frequently  in  the  young ;  in  the  old  (from  this  cause  as  well 

as  from  degeneration),  dis- 
ease is  rather  more  com- 
mon in  the  aortic  valve. 
The  forms  of  disorder,  indi- 
cated by  murmurs,  occur 
in  the  following  order  of 
frequency  :  1st,  Aortic  ob- 
structive ;  2d,  Mitral  regur- 
gitant ;  3d,  Aortic  regur- 
gitant ;  4th,  Aortic  obstruc- 
tive and  mitral  regurgitant 
together. 

Enlargement  of  the  heart, 
either  with  muscular  thick- 
ening [hypertrophy]  or  with 
attenuation  {dilatation ),  is 
a  common  consequence  of 
Already  (see  Semeiology)  the 


Fibroid  Thickening  of  Mitral  Valve. 


endocarditis  with  valvular  le'sion 

statement  of  Dr.  Stokes  has  been  adopted,  that  in  every  case  the 
important  question  is,  less  the  state  of  the  particular  valves,  than 
the  amount  of  interference  with  the  functional  action  of  the  heart. 
In  young  persons,  remarkable  recoveries  sometimes  take  place  (as 
I  have  seen)  from  very  considerable  lesion  of  the  valves.  In  other 
instances,  adaptation  of  the  heart  itself,  and  of  the  general  system, 
by  degrees,  is  effected,  so  that  quite  good  health,  and  even  capacity 
for  exercise,  may  be  attained,  while  the  physical  signs  of  the  local 
organic  change  remain.  Sudden  death  is  less  common  in  heart 
disease  than  fs  popularly  supposed.  Some  persons  having  it  have 
lived  twenty  or  thirty  years. 


VALVULAR  DISEASE. 

The  valves  of  the  heart  may  be  impaired  either  by  inflammation, 
or  by  degeneration  (e.  g.,  calcareous  deposit  or  "ossification"). 
The  latter,  degenerative  valvular  changes,  occur  gradually ;  and 
mostly  late  in  life.  Either  form  of  valve-disease,  or  at  least  of 
valvular  alteration,  is  generally  permanent ;  the  degenerative  form 
most  invariably  so. 

Changes  may  occur  by  simple  thickening,  or  by  deposits  of 
fibroid,  fatty,  or  calcareous  material ;  or  by  atrophy,  contraction, 
adhesion,  or  ulceration  of  the  valves  ;  or  gouty  deposits  of  urates 
and  carbonates  of  soda  and  lime.  The  valve  (mitral  or  aortic 
primarily,  tricuspid  or  pulmonary  secondarily)  may  be  thus  ren- 
dered incapable  either  of  perfect  closure,  or  of  full  opening ;  in 
most  instances,  a  permanently  half-open  state  results. 

A  considerable  variety  of  pathological  conditions  may  exist  in 
organic  disease  of  the  heart ;  while  tlie  number  of  cases  in  which 
an  exact  and  unequivocal  diagnosis  can  be  made,  is  comparatively 
small.  We  must  not  confine  attention  at  all  to  the  physical  signs 
alone,  but  compare  with  these  the  pulse,  and  force  of  the  heart, 
with  other  general  symptoms,  and  the  entire  history  of  the  case. 


VALVULAR    DIHEAKE, 


24h 


Atheroma  of  Aortic  Valve. 


It  is  possible^  thourrh  very  uncoinmon,  for  valvular  disease  (espe- 
cially mitral  obstruction)  to  exist  without  any  murmur. 

CertainUj  can  hardly  evcr.l)e  obtained,  luiless  it  be  in  the  diag- 
nosis of  one  of  the  followinu  three  conditions: — 

1.  Uncomplicated  disease  of  thenutral  valve.  Signs  of  this  are, 
— a  permanent  murmur  with  the  first  sound  loudest  towards  the 
apex   and  left  side,  and  not 

heard   over    the    aorta  ;  the  Fig.  89. 

second  sound  natural.  The 
heart's  action  natural  ;  the 
impulse  not  excited,  the  pulse 
natural.  A  presystolw  mur- 
mur, just  before  the  first 
sound,  has  been,  by  Gaird- 
ner,  Salter,'  and  others,  re- 
ferred to  constriction  of  the 
mitral  valve.  It  is  often  ac- 
companied by  thrill,  and  as- 
sociated with  haemoptysis. 
Dr.  Gowers,  especially,  has 
pointed  out-  that  this  mur- 
mur  is   often    much    louder 

when  the  patient  is  lying  down  than  vs^hen  sitting  up.  I  found  it 
entirely  inaudible  in  one  case,  except  when  the  patient  (a  child) 
was  recumbent. 

2.  Disease  of  the  aortic  valves  with  permanent  openness.  With 
this,  there  is  no  murmur  with  the  first  sound  ;  the  second  sound  is 
replaced  by  a  double  murmur,  loudest  at  the  base  of  the  heart,  and 
heard  along  the  aorta.  In  an  advanced  stage  of  this  condition, 
the  arteries  give  to  the  finger,  or  even  to  the  eye,  an  imi^ression  of 
bnundhig  pulsation  ;  with  ajerJdmj,  or  abruptly  ending  pulse  at  the 
wrist.  Quincke  and  Otto  Becker  liave  observed,  with  the  ophthal- 
moscope, pulsation  of  the  retinal  vessels  in  cases  of  aortic  valvular 
hisutficiency.^ 

3.  Disease  of  the  aortic  valves  without  permanent  openness. 
Here,  the  action  of  the  heart  is  slow  and  feeble,  generally  regular, 
or  only  occasionally  intermitting.  A  murmur  is  heard  with  the 
first  sound,  the  second  sound  being  healthy  ;  but  a  murmur  may 
be  heard  with  the  second  sound,  in  the  aorta  and  carotids. 

It  must  be  remembered  that  in  anmniia,  without  heart  disease, 
a  bellows-murmur  is  often  heard,  extending  into  the  arteries. 
Chiefly  by  the  concurrent  signs  and  symptoms  is  this  to  be  dis- 
tinguished from  organic  disease  of  the  heart.  Anaemic  and  func- 
tional murmurs  are  more  variable,  and  are  not  much  increased 
by  moderate  exercise.  Even  organic  murmurs,  however,  are,  in 
some  rare  instances,  variable. 

When  the  aortic  valvular  orifice  is  greatly  contracted^  the  pulse 
at  the  wrist  may  become  very  feeble,  almost  absent ;  while  the 
heart's  impulse  is  strong. 

Dr.  T.  B.  Peacock'  considers  it  to  be  the  result  of  his  experi- 


1  L.ancet,  Oct.  23  and  Oct.  30,  1RG9. 

3  Loudon  Oplithalin.  Hospital  Ruperts,  February,  1873. 

*  St.  Thonia.s's  Hospital  Keports,  vol.  ii. 

21* 


London  Practitioner,  1873. 


246       DISEASES   OF   ORGANS    OF    CI  RCTTL  ATION  . 


ence,  that  incompetency  of  the  valves  is  a  more  serious  defect  than 
obstruction ;  incompetency  of  the  aortic  being  more  dangerous 
than  that  of  the  mitral  valve.  Obstructive  disease  of  the  mitral, 
however,  he  regards  as  more  unfavorable  than  that  of  the  aorta 
in  prognosis. 

Fig.  90. 


Diagram  showing  the  areas  over  which  murmurs  produced  in  the  different 
valves  of  the  heart  are  chiefly  audible.  A.  Seat  of  Mitral  murmur.  B. 
Seat  of  Aortic  murmur,  c.  Seat  of  Tricuspid  murmur.  D.  Seat  of  Pulmo- 
nary arterial  valvular  murmur,  r.  v.  Eight  Ventricle.  I.  v.  Left  Ventricle. 
I.  au.  Left  Auricle,  r.  au.  Right  Auricle,  ao.  Aorta,  v.  c.  Vena  Cava. 
(Gairdner.) 

Advanced  mitral  or  aortic  disease  is  accompanied  usually  by 
derangement,  sympathetic  or  obstructive,  of  the  lungs,  liver,  and 
other  organs ;  with  haemoptysis,  anasarca,  cyanosis,  irregularity 
of  the  pulse,  syncope,  etc.  Pulsation  of  the  jugular  veins  usually 
indicates  secondary  disorder  upon  the  right  side  of  the  heart, 
with  regurgitation  into  the  vense  cavse.  Pseudo-apoplectic  syncope 
may  occur  in  permanent  patency  of  the  mitral  valve  ;  or  in  fatty 
degeneration  of  the  heart,  with  or  without  valvular  disease. 

Tor  an  account  of  the  Sphygmograph,  and  its  uses  in  diagnosis, 
see  Semeiology,  Part  I. 

DILATATION  OF  THE  HEAST. 

Uncomplicated  dilatation  of  the  whole  heart,  or  of  either  pair 
of  corresponding  cavities,  or  of  any  one  cavity,  is  very  uncommon. 


DILATATION    OF    THE    HEART.  247 

Complicated  dilatation  is  frequent.  It  may  depend— 1,  on  a 
debilitated  state  of  the  cardiac  muscle  ;  2,  on  valvular  disease; 
3,  on  obstruction  beij;inning  in  organs  remote  from  tbe  heart. 

The  connnonest  form  of  dilatation  is  part  of  a  triple  affection, 
in  which  the  heart,  liim/s,  and  liver  are  together  involved.  All 
this  may  come,  in  the  first  place,  from  a  cachexia,  such  as  gout, 
or  scurvy,  or  from  simple  anaemia.  Exacerbations  in  the  disorder 
may  occur;  as,  of  pulmonary  congestion,  enlargement  of  the 
hver,  cardiac  asthma,  bronchitis,  or  dropsy.  The  prognosis 
cannot  be  very  favorable  in  such  a  case ;  and  only  palliative  or 
recuperative  treatment  avails,  along  with  hygienic  management, 
to  economize  the  powers  of  nature. 

Enlargement  of  the  heart  is  indicated,  upon  physical  explora- 
tion, when,  with  extended  impulse  of  the  heart,  we  have  dulness 
on  percussion  beyond  the  usual  limits.  If  true  hypertrophy  or 
muscular  thickening  be  present,  the  impulse  is  very  forcible  as 
well  as  extended.  The  heart-sounds  are  apt  to  be  clear,  though 
not  loud,  in  attenuated  dilatation  ;  rather  loud,  but  dull  toned, 
in  enlargement  with  thickening  of  the  Avails.  But  these  differ- 
ences are  hardly  to  be  relied  upon.  Bulging  of  the  pericardial 
region  is  sometimes  quite  distinct  in  children. 

Hypertrophy  of  the  muscular  tissue  of  the  heart  is  most  often 
induced  by  valvular  obstruction  or  regurgitation,  compelling 
unusual  and  continued  effort  to  sustain  the  circulation.  It  is 
also  a  not  uncommon  attendant  of  Bright's  disease  of  the 
kidnej's.^ 

Sometimes,  however,  it  is  more  truly  idiopathic;  following 
causes  of  over-action  of  a  heart  otherwise  sound.  Thus  violent 
exercise,  self-abuse,  coffee,  alcohol,  tobacco,  etc.,  are,  with  good 
reason  in  predisposed  cases,  accused  of  producing  it. 

Dr.  Quain  has  described  a  condition  of  cardiac  enlargement 
which  he  considers  to  be  a  hypertrophy  (hyperplasia)  of  the  con- 
nective tissue  of  the  heart. ^ 

In  the  treatment  of  simple  hypertrophy,  avoidance  of  exciting 
causes,  and  particularly  of  violent  exercise,  alcohol,  and  venery, 
is  the  main  principle.  Robust  or  plethoric  patients  will  bear  and 
will  be  benefited  by  moderate  venesection,  at  long  intervals  ;  or 
by  occasional  leeching  or  cupping  over  the  heart.  Acetate  of  lead 
[F.  41],  as  an  astringent  cardiac  sedative,  is  recommended  by 
some,  and  is  worthy  of  trial  (one  grain  thrice  daily),  with  care 
to  avoid  saturnine  poisoning. 

Digitalis  was  formerly  relied  upon  as  a  reducer  of  cardiac 
action.  Lately  it  is  regarded,  instead,  as  a  tonic  to  the  heart 
(probably  through  ganglionic  influence),  lessening  its  rapidity  of 
action  only  when  that  "depends  on  debility.  Brunton,  Gull,  and 
Fothergill  consider  its  use  unsafe  when  there  is  fatty  degenera- 
tion of  the  heart.  I  think,  however,  that  evidence  has  been 
given  (Withering,  17S5 ;  Holland,  Fuller,  H.  Jones,  Traube)  to 
encourage  us  to  use  digitalis  [F.  42,  43]  moderately,  where  abnor- 
mal rapidity  of  the  heart's  action  exists  in  conditions  of  debility ; 

1  In  100  cases,  Dr.  Bright  found  hypertrophy  of  the  heart  in  52 ;  and  in  34  of  these 
there  was  no  evidence  of  valvular  affection, 
a  Briiidh  Med.  Journal,  Mrtrch  23,  1872. 


248      DISEASES  OF  OEGANS   OF  CIECULATION. 

and  to  expect  more  from  veratrum  viride  [F.  44]  as  a  sedative 
and  palliative,  in  violent  acceleration  of  the  pulse,  as  in  muscular 
hypertroi^hy,  and  some  forms  of  palpitation.  Benefit  may  attend, 
in  like  cases,  upon  the  use  of  wild  cherry  hark.  An  exclusive 
milk  diet  is  recommended  by  Drs.  Karell  and  Pechalier,  in  car- 
diac enlargement  and  other  chronic  aflfections.  In  attenuated 
dilatation  of  the  heart,  neither  reason  nor  experience  affords 
ground  for  the  approval  of  such  a  regimen. 

FATTY  DEGENERATION  OF  THE  HEART. 

Definition.^Suhstitution  of  fatty  substance  for  the  muscular 
tissue  of  the  heart,  to  such  an  extent  as  to  interfere  with  its 
normal  action. 

Symptoms  and  Course. — Though  no  doubt  almost  always 
gradual  in  its  progress,  this  affection  in  many  instances  fails  to 
make  itself  known  by  symptoms  until  a  late  period ;  sometimes 
even  till  the  moment  of  death.     Usually,  feebleness  and  irregu- 

FiG.  91. 


Fatty  Degeneration. 

larity  of  the  pulse  and  heart's  impulse  are  observed ;  with  exhaus- 
tion and  dyspnoea  upon  exertion.  The  pulse  is  slow  when  at 
rest ;  sometimes  only  thirty  or  forty  in  the  minute,  although  the 
heart  beats  fifty  or  sixty  in  the  same  time.  Attacks  of  apoplec- 
tic syncope  or  syncopal  apoplexy  may  occur ;  at  first  most  like 
syncope,  after  repetition  becoming  more  apoplectic.  These  are 
distinguished  from  true  apoplexy  by  the  feebleness  of  the  pulse, 
coldness  of  the  skin,  sighing  respiration,^  and  the  slightness  or 
absence  of  paralytic  symptoms,  notwithstanding  several  repeti- 
tions of  the  attack.  They  are  made  worse  by  depletion  or  reduc- 
tion of  the  system ;  and  may  be  relieved  or  warded  off  by  timely 
stimulation ;  the  recumbent  position  is  most  favorable  in  them. 
The  first  attack  of  this  kind  may,  however,  prove  fatal. 
Physical  Signs. — Fatty  degeneration  is  often  complicated  by 


1  "Ascending  and  descending  breathing"  of  Cheyne  and  Stokes.  It  is  a  succession 
of  increasing  and  then  decreasing  acts  of  respiration,  with  an  interval  of  apnoea  so  long 
that  the  patient  may  seem  to  be  dead. 


SUDDEN     DEATH     IN    HEART     DISEASE.        249 


the  presence  of  other  structural  changes  of  the  heart.  By  itself, 
it  is  with  dinieuUy  diagnosticated  hy  physical  exploration.  The 
heart's  impulse  is  feel)le  and  slow,  often  irregular,  and  the  sounds 
weak.  A  bellows-niurmur  is  frequently  heard  with  one  or  Ijoth 
sounds. 

Morbid  Anatomy. — True  fatty  degeneration  must  he  distin- 
guished from  fatty  accumulatioyi  about  the  heart ;  which  may 
impede  its  action,  but  is  much  less  dangerous.  In  true  inter- 
stitial degeneration,  the  heart  is,  in  part  or  througliout,  flabby 
and  pale,  or  yellowish,  though  it  may  be  more  bulky  than  usual. 
Minutely  examined,  the  muscular  fibrils  are  found  to  have  lost 
their  transverse  strire,  and  to  have  resolved  themselves,  more  or 
less,  into  streaks  of  oil-dots  or  opaque  granules. 

Death,  sometimes,  is  shown  to  have  resulted  from  rupture  of 
the  heart.  In  other  instances  that  organ  has,  under  some  exer- 
tion or  excitement,  becomes  exhausted  and  failed  to  act  suffi- 
ciently to  keep  up  the  circulation. 

Prognosis. — Recovery  is  not  to  be  expected  in  cases  of  fatty 
degeneration  ;  although  life  ma}'  be  prolonged  to  old  age.  Much 
will  depend  upon  circumstances  of  living,  and  care  to  avoid  dis- 
turbing agencies. 

Causation.— In  early  life  this  affection  is  uncommon;  its  most 
frequent  cause,  then,  is  pericardial  or  endocardial  inflammation. 
Most  cases  occur  after  flfty  years 
of  age.  It  then  comes  as  one  of  the 
local  manifestations  of  waning  vital 
energy  ;  but  it  may  be  promoted  by 
any  or  all  exhausting  or  depressing 
causes.  No  special  or  peculiar  line 
of  causation  can  be  pointed  out. 

Treatment. — This  can  be  only 
conservative.,  not  curative.  Tonics, 
particularly  iron,  with  generous 
diet,  sea,  or  mountain  air,  change 
of  scene,  avoidance  of  anxiety  and 
exertion,  may  do  much  to  retard 
the  degenerative  process.  Violent 
effort  or  emotional  excitement  may 
be  suddenly  fatal.  Tranquil  occu- 
pation only  should  be  selected,  and 
all  rapid  exercise,  and  even  strain- 
ing at  stool,  ought  to  be  avoided. 


Fig.  92. 


Rupture  of  Heart. 


MODES   OF   SUDDEN  DEATH  IN  HEAKT  DISEASE. 

We  may  briefly  enumerate  these  as,  1.  Arrest  of  the  heart's 
action  from  debility  of  the  muscular  walls  ;  2.  Spasm  of  the  ven- 
tricles ;  3.  Extreme  obstruction,  or  regurgitation ;  4.  Rupture ; 
5.  Heart-clot.     Indirectly,  cerebral  or  pulmonary  apoplexy. 

Of  heart-clot,  i.  e.,  fibrinous  deposit  in  the  heart  before  death 
(undoubtedly  a  rare  occurrence),  the  signs  have  been  well  pointed 
out  by  Dr.  B.  W.  Richardson.^  They  are  dyspnoea,  not  other- 
wise accounted  for,  pallor,  fluttering  pulse,  and  prostration,  with 

1  Med.  Times  and  Gazette,  Nov.  21, 1868. 


250      DISEASES   OP   ORGANS   OF   CIRCULATION. 

deficiency  of  one  or  both  sounds  of  the  heart,  on  the  right  or  left 
side,  according  to  the  position  of  the  deposit.  Yery  seldom 
indeed  does  heart-clot  form  long  before  death  ;  reduction  of  vital 
energy  seeming  to  be  its  essential  condition.  In  autopsic  exami- 
nations, an  ante-mortem  clot  is  characterized,  1st,  by  its  filling  a 
cavity  ;  2d,  its  being  grooved  externally  by  a  current  of  blood, 
or  bored  by  a  current  through  its  centre  ;  .3d,  its  being  firmly 
adherent  by  a  mechanical  or  organic  tie  to  the  walls  of  the  heart 
or  vessel;  4th,  its  structure  being  laminated,  or  containing  in  its 
centre  broken  up  fibrin  ;  6th,  its  being  deeply  indented  by  the 
surrounding  structures. 

ANGINA  PECTOEIS. 

Definition. — An  irregularly  paroxysmal  disorder,  characterized 
by  sudden  attacks  of  severe  pain,  extending  from  the  heart  along 
the  left  arm,  with  a  sense  of  stricture  in  the  chest,  jorostration,  and 
alarm.     The  attacks  are  especially  apt  to  come  on  while  walking. 

Pathology  and  Causation. — This  appears  to  be  a  symptomatic 
affection ;  a  neurosis,  connected  in  most,  though  not  in  all  cases, 
with  organic  disease  of  the  heart  ;  especially  ossification  of  the 
coronary  arteries.  Gout  predisposes  to  or  excites  it,  but  probably 
not  in  the  absence  of  heart-lesion.  It  occurs  generally  in  old 
people  ;  most  often  in  men.  Seneca,  John  Hunter,  and  Dr.'Chal- 
mers  have  been  among  its  distinguished  victims.  Weakness  of 
the  muscular  fibre  of  the  heart  is,  very  probably,  important  in 
predisposing  to  it ;  and  it  may  be,  Sir  T.  Watson  conjectures, 
especially  dependent  upon  fatty  degeneration  of  the  heart.  Lau- 
der Brunton  has  explained  (1866)  the  occurrence  of  its  paroxysms 
by  spasmodic  contraction  of  the  coronary  arterioles.  Probably  this 
may  account  for  most,  but  not  for  all  cases  of  the  disease  ;  but  it 
leaves  the  origination  of  the  arterial  spasm  still  to  be  accounted  for.^ 

Prognosis  and  Duration. — The  attack  may  last  from  a  few 
minutes  to  an  hour,  or  even  a  day.  Commonly  it  is  short,  going 
off  with  perspiration  or  copious  urination.  A  first  attack  may 
be  fatal.  Returns  occur  at  variable  intervals — days,  weeks,  or 
months ;  each  one  generally  sooner  or  more  violent,  till  one  of 
them  ends  life.  Persons  subject  to  angina  pectoris  may,  how- 
ever, live  for  many  years. 

Treatment.— Stimulants  and  anodynes  [F.  47,  48,  49]  are  indi- 
cated during  the  attack.  Best  will  be  Hofiinann's  anodyne,  laud- 
anum, Warner's  cordial,  and  whisky,  in  moderate  doses,  repeated 
in  a  short  time  if  necessary  ;  with  mustard  plasters  over  the  chest 
and  between  the  shoulders,  and  the  warm  footbath.  Where  gout 
is  present,  colchicum  [P.  45,  46]  and  alkalies  are  important. 
Arsenic  is  said  (Philipp)  to  have  done  good  in  the  interval;  and 
inhalation  of  a  few  drops  of  nitrite  of  amyl  (Thompson,  Madden), 
during  the  paroxysm.     Electricity  is  worthy  of  careful  trial. 

EXOPHTHALMIC  GOITRE. 
Synonyms. — Thyro-cardiac  Disorder  ;  Parry''s  Disease  (1825) ; 
Graves''  Disease;  Dasedoiv''s  Disease. 

J I  saw  a  case  in  1879,  in  which,  after  angina  pectoris  of  many  years'  standing,  autopsy 
revealed  no  positive  lesion  of  the  heart,  sufficient  to  account  for  any  morbid  symptoms. 
A  number  of  similar  cases  have  been  observed. 


E  X  ()  P  II  T II  A  I.  M  I  C    G  O  I T  II  E . 


251 


Definition.—  EnlarfftMiicnt  of  the  thyroid  gland  in  the  neck,  with 
overaction  of  the  heart  and  Cervical  vessels,  and  prominence  of 
the  eyeballs. 

Nature. — This  uncommon  affection  is  considered  by  Dr.  Stokes 
to  consist  in  a  more  or  less  permanent  functional  excitement  of 
the  heart ;  which  may  prodiun;  finally  dilatation  and  hypertrophy, 
with  dilatation  also  of  the  carotid  arteries  and  jugular  veins,  and 


Fig 


Exophthalmic  Goitre.     (Yeo.) 

an  aneurismal  condition  of  the  thyroid  gland.  Although  consid- 
erable disturbance  and  prostration  of  the  system  must  attend 
such  a  state  of  things,  yet  it  has  been  repeatedly  recovered  from. 
The  cause  of  the  affection  has  not  been  made  out,  Virchow  asserts 
the  heart  to  be  found,  after  death,  greatly  dilated  ;  sometimes  the 
aorta  and  other  large  vessels  arc  atheromatous.'     Cruise  and 


1  Atheroma,  a  grucl-Iike  or  pulp-like  change. 


252       DISEASES   OF   ORGANS   OF   CIRCULATION. 

McDonnell,  as  well  as  Recklinghausen,  ha,ve  observed  marked 
changes  in  the  cervical  sympathetic  ganglia.^  Cheadle  (St.  George's 
Hospital  Reports,  1877-78),  dwells  with  emphasis  upon  the  dila- 
tation of  the  arteries  in  this  disorder.  A  case  which  I  studied  in 
1879  impressed  me  with  the  prominence  of  atonic  relaxation  and 
dilatation  of  the  whole  cardlo-vascular  system  in  its  pathology. 
Behind  this,  there  probably  is  a  morbid  condition  of  the  cervical 
ganglia  ;  Cheadle  believes,  of  the  upper  part  of  the  spinal  marrow. 

Treatment. — To  tranquillize  the  heart  is  the  main  indication. 
Veratrum  viride^  in  doses  not  at  all  nauseating  (two  or  three  drops 
of  the  tincture  every  three  or  four  hours),  may  be  persevered  in 
for  a  while,  watching  its  effects.  Other  treatment  must  depend 
upon  the  general  condition  of  each  patient.  Of  course  violent 
exercise  and  mental  excitement  must  be  avoided. 

Dr.  Cheadle  advises  absolute  rest.  Iron  and  digitalis  appear  to 
do  more  good  (as  I  have  seen)  than  any  other  medicines  [F.297]. 
They  should  be  continued  (with  occasional  interruptions,  for  a  few 
days)  through  a  long  period.  Without  insisting  upon  rest  in 
bed,  I  would  urge  the  patient  to  avoid  all  efi'orts  which  decidedly 
hurry  the  action  of  the  heart.  Dusch,  Meyer,  Eulenburg,  and 
others  have  reported  favorable  results  as  following  the  applica- 
tion of  continuous  electrical  currents  to  the  sympathetic  nerve,  or 
to  its  vicinity  in  the  neck.^ 

PALPITATION. 

All  excessive  or  consciously  disturbed  action  of  the  heart  is 
commonly  thus  designated.  Overaction,  in  particular,  may  have 
either  of  the  following  origins  : — 

1.  Iffervous,  or  hysterical ;  2.  Dyspeptic ;  3.  Rheumatic  or 
gouty ;  4.  HjrpertropMc. 

Nervous  palpitation  occurs  in  anaemic  persons,  especially  hys- 
terical females,  or  in  those  otherwise  debilitated.  Alcoholic 
intemperance,  strong  coffee,  tobacco,  excessive  venery  or  self- 
abuse  may  produce  it. 

Dyspepsia  is  very  often  attended  by  palpitation,  sympathetic 
with  the  gastric  disturbance.  Usually,  in  such  a  case,  it  is  worst 
after  meals. 

Gouty  and  rheumatic  palpitations  are  common.  Their  nature 
will  be  made  known  by  the  presence  of  other  signs  of  the  con- 
trolling diathesis. 

All  of  the  above  forms  of  merely  functional  disturbance  of  the 
heart,  and  especially  the  purely  nervous,  may  be  known  from 
hypertrophic  overaction,  and  from  that  of  attenuated  dilatation 
of  the  heart,  by  the  fact  that  they  are  not  increased  by  moderate 
exercise  ;  are  often,  indeed,  much  diminished  thereby.  When  the 
heart  is  enlarged,  especially  with  valvular  change,  active  move- 
ment causes  distress  and  dyspncea,  with  great  acceleration  of  the 
cardiac  movement.  In  palpitation  of  all  kinds,  during  the  attack, 
it  is  generally  not  possible  to  lie  with  ease  upon  the  left  side ;  and 
orthopncEa  may  occasionally  occur,  without  organic  disease. 

1  Irish  Hospital  Gazette,  Sept.  1,  1873. 

2  London  Practitioner,  March,  1874. 


ANEUKISM    OF    THE    THORACIO    AOliTA.       253 

The  treatment  of  palpitation  must  vary  according  to  its  cause. 
If  nervous  in  origin,  invigoration  of  tlic  system  and  enrichment 
of  the  blood  arc  probably  needed  ;  by  iron  and  other  tonics,  and 
regimen  ;  especially  avoiding  a  too  sedentary  life.  Dyspepsia  will 
require  appropriate  treatment ;  as  a  part  of  which,  exercise  in  the 
open  air  will  not  be  counter-indicated  at  all  by  sympathetic  pal- 
pitation. 

Functional  overaction  of  the  heart,  without  organic  disease,  is 
in  itself  not  dangerous.  It  is  alarming,  however,  to  the  patient, 
as  well  as  a  source  of  discomfort ;  and  may,  if  long  sustained, 
bring  on  true  enlargement  of  the  heart.  All  causes,  therefore, 
of  such  disturbance  ought  to  be  sedulously  avoided. 

CARDIAC  EXHAUSTION. 

In  U.  S.  general  hospitals  during  the  civil  war,  under  my  own 
observation'  as  well  as  that  of  other  practitioners,  quite  a  num- 
ber of  cases  of  soldiers  presented,  who  were  rendered  unfit  for 
duty  by  heart-symptoms,  and  yet  without  signs  of  valvular  or 
other  organic  disease.  Careful  investigation  of  these  satisfied 
me  that  the  condition  was  one  of  muscular  exhaustion  of  the 
heart ;  owing  to  hard  marching  with  deficiency  both  of  rest  and 
food  ;  especially  during  McClellan's  peninsular  campaign.  Symp- 
toms of  this  were — constantly  rather  rapid  though  not  strong 
pulse,  with  less  than  normal  vigor  of  the  impulse  of  the  heart ;  the 
acceleration  being  increased  greatly,  with  dyspnoea,  upon  even 
slight  exertion.  The  sounds  of  the  heart  were  not  altered  except 
in  the  diminution  of  duration  and  force  of  the  first  sound,  making 
it  more  like  the  second.  After  many  months  of  rest  these  men 
improved,  so  as  to  be  likely  to  recover.  No  special  treatment 
seemed  to  be  required.  British  army  surgeons  have  ascertained 
beyond  doubt  ■^  that  functional  heart  atlections  are  decidedly  more 
frequent  among  soldiers  than  in  civil  life.  The  explanation  pro- 
posed for  this  is,  the  unsuitable  construction  of  the  accoutrements 
of  the  soldier,  unduly  compressing  the  chest  and  obstructing  the 
movements  of  the  heart.  Dr.  Myers  asserts  that  "irritability. 
of  the  heart"  is  shown  very  early  by  the  sphygmograph ;  a 
marked  dicrotism  being  always  presented.  Attention  has  been 
latterly  called,  by  Fothergill  and  others,  to  the  not  infrequent 
action  of  ancemia  in  promoting  heart  disorder.  Heart  starvation 
is  probably  (in  people  who  are  under-fed,  over-worked,  or  sufier- 
ing  from  worry)  often  overlooked,  or  mistaken  for  fatty  degenera- 
tion of  the  heart.  I  am  familiar  with  the  case  of  a  distinguished 
literary  man  who,  a  dozen  years  ago,  was  told  by  an  eminent 
practitioner  that  he  had  incurable  disease  of  the  heart ;  but  who, 
after  a  few  months  of  rest,  recovered  his  health,  with  full  capacity 
for  work,  lasting  to  this  time. 

ANEUmSM   OF  THE  THORACIC  AORTA. 
A  bulgingf  in  the  front  of  the  chest,  in  which  pulsation  is  felt, 
not  continuous  or  identical  with  that  of  the  heart,  and  over  which 

1  Trans,  of  College  of  Physicians  of  Philadelphia,  in  Am.  Journ.  of  Med.  Sciences, 
July,  1864.    Drs.  Stille  and  i)a  Costa  described  this  affection  at  about  the  same  time. 

-  Myers,  Alexandra  prize  essay  on  Diseases  of  the  Heart  among  Soldiers.  London, 
1870. 

22 


254      DISEASES   OF  ORGANS  OF  CIECUL ATION. 


resonance  upon  percussion  is  dull — is  probably  an  aneurismal 
tumor.  If  a  thrill  also  is  perceptible  in  it,  with  or  without  a 
murmur  on  auscultation,  we  may  be  still  more  confident  in  the 
diagnosis ;  and  when  the  signs  of  pressure  upon  the  air-tubes, 
oesophagus,  sympathetic  or  recurrent  laryngeal  nerve,  vena  cava 
or  thoracic  duct  occur,  it  is  nearly  certain.  From  sphygmographic 
observation,  Marey,  Mahomed  and  Franck  infer  that  abnormal 
delay  of  the  arterial  pulse,  after  the  cardiac  impulse,  is  a  sign  of 
aortic  aneurism  ;  but  there  are  exceptions  to  this  rule. 

Murmur  may,  however,  be  absent ;  so  may  thrill ;  the  bulging 
may  be  slight,  and  the  percussion-resonance  little  altered.  The 
sign  of  most  consequence  is,  the  existence  of  two  points  of  pulsa- 
tion in  the  chest,  the  cardiac  and  the  aneurismal ;  the  latter  coin- 
ciding almost  with  the  diastole  of  the  heart. 

The  signs  of  pressure  are,  chiefly,  pain,  cough,  dyspnoea,  loss 
of  voice,  difficulty  of  swallowing ;  and  (as  I  have  seen  in  one 
instance)  emaciation  from  obstruction  of  the  thoracic  duct. 

Cancerous  or  other  tumors  may  produce  all  these  latter  signs ; 
but  such  tumors  do  not  pulsate.  In  empyema  the  beat  of  the 
heart  sometimes  impels  the  fluid  so  as  to  throb  somewhat  widely ; 
but  this  is  a  single  cardiac  impulse.  Occasionally  a  consolidated 
lung,  in  phthisis,  may  vibrate  forcibly  with  the  pulmonary  artery ; 

but  other  signs  then  make 
Fig.  94.  clear  the  disease.     There 

are,  however,  cases  of  tho- 
racic aneurism  entirely 
latent^  until  death ;  no  dis- 
tinct sign  making  the  affec- 
tion known,  even  to  a  care- 
ful observer. 

The  course  of  aortic 
aneurism  is  usually  veiy 
gradual — often  lasting  for 
a  number  of  years.  Death 
occurs  —  1,  from  sudden 
rupture  and  copious  hem- 
orrhage ;  2,  from  slighter 
rupture  and  slow  leakage  ; 
3,  from  slow  exhaustion  by 
pressure,  interfering  with 
respiration,  deglutition, 
etc. 

The  causation  of  tho- 
racic aneurism  is  obscure. 
It  occurs  nearly  always  in 
rather  elderly  people,  in 
whom  the  process  of  degen- 
eration of  the  vessels  has  commenced ;  but  now  and  then  it  is  met 
with  before  middle  life.  It  is,  relatively,  frequent  among  soldiers. 
Syphilis  appears  sometimes  to  predispose  to  it.  Dr.  Bruen^ 
found  evidences  of  a  syphilitic  history  in  fifty-five  out  of  sixty- 
nine  cases  of  aortic  aneurism  in  two  Hospitals  in  Philadelphia. 


Aneurism  of  the  Aorta. 


1  Phila.  Med.  Times,  May  21, 1881,  p.  517. 


ABDOMINAL    AORTIC    ANEUllISM 


2r>5 


Similar  observations  have  been  made  concerning  cases  occurring 
amongst  soldiers  (as  at  the  Hospital  at  Nctley,  England).  But 
it  is  very  improbable  that  any  such  i)redominance  of  this  mode 
of  causation  exists  in  ordinary  civil  life. 

The  following  points  may  be  added  in  regard  to  its  clinical  his- 
tory (see  Stokes  on  the  Heart  and  Aorta) :— 1.  The  effects  of  the 
aneurismal  pressure  may  vary  from  time  to  time ;  much  more 
thfin  they  do  in  cancer.  2.  The  aneurismal  impulse  may  be  even 
stronger  than  that  of  the  heart ;  but  a  feeble  impulse  in  some 
instances  attends  a  large  aneurism,  3.  Destruction  of  one  or 
more  vertebra;  from  absorption  under  pressure  (as  shown  by 
autopsy)  is  not  uncommon.  4.  Phthisis  is  often  associated  with 
aneurism  of  the  aorta. 


ABDOMINAL  AOETIC  ANEURISM. 

Of  this,  the  signs  and  symptoms  are — deep-seated  severe  pain 
(occasionally  intermitting)  in  the  back  and  abdomen,  increased 
by  certain  movements ;  unaccompanied  by  fever,  but  resisting  all 
treatment ;  later,  muscular  spasms  of  the  lower  limbs,  displace- 
ment of  the  liver,  and  the  manifestation  of  a  pulsating  abdominal 
tumor,  felt  upon  palpation,  over  which  there  is  dulness  of  reso- 
nance upon  i^ercussion.  The  higher  up  the  aneurism,  the  more 
severe  are  the  pains  and  other  symptoms  of  disturbance. 

Aneurism  of  the  aorta  may,  without  careful  examination,  be 
confounded  with  aortic  pulsation  v/ithout  tumor  (common  in  dys- 
pepsia, etc.),  or  with  neuralgia,  rheumatism  of  the  bowels,  colic, 
worms,  disease  of  the  liver,  caries  of  the  spine,  psoas  abscess, 
or  cancer.  Only  the  discovery 
of  a    distinctly    puhating    tumor  ^i<^«  95. 

(not  a  tumor  moved  by  subjacent 
pulsation)  can  establish  the  pres- 
ence of  aneurismal  disease.  An 
additional  sign  of  value  is  a  local- 
ized "bruit"  or  aortic  murmur 
heard  along  the  course  of  the 
spine.' 

The  treatment  of  either  thora- 
cic or  abdominal  aortic  aneurism 
is  usually  not  hopeful.  Hi/gienic 
measures  maj'  retard  decline,  and 
careful  self-management  may 
avert  a  sudden  catastrophe  ;  that 
is  mostly  all.  Exertion  and  ex- 
citement must,  of  course,  be  pro- 
hibited altogether.  Dr.  Sibson 
urges  the  importance  of  limiting 
the  amount  of  fluid  taken  by  the 
patient,  to  a  pint  daily  ;  in  order 

to  lessen  the  volume  of  the  blood,  Aortic  Aneurism, 

and    thus    reduce    the    pressure 

upon  the  sac.     Tufnell  insisted  upon  entire  rest,  with  low  diet, 
for  mouths  together.     The  medicine  most  in  favor  for  aneurism 


1  W.  Moore,  iu  Dublin  Quarterly  Journal  of  Medicine,  August,  1869. 


256      DISEASES   OF   ORGANS   OF   CIRCULATION. 

of  the  aorta  with  leading  practitioners  is  iodide  of  potassium 
(ISTelaton,  Balfour).  Excellent  effects  are  ascribed  to  it  in  a 
number  of  reported  cases. 

Electro-puncture  (Ciniselli,  1846)  has  succeeded,  in  a  few  instan- 
ces, in  curing,  and  in  a  greater  number,  temporarily  relieving, 
aneurism  of  the  thoracic  aorta.  It  is  applicable  only  to  cases  in 
which  the  aneurism  approaches  closely  to  the  wall  of  the  thorax. 
It  may  then  be  performed  without  danger.  Petit  ^  advises  not 
delaying  it  (after  other  treatment  has  failed)  until  an  external 
tumescence  has  formed  ;  statistics  showing  the  best  results  when 
that  event  has  been  anticipated. 

For  galvano-puncture,  a  battery  of  moderate  intensity  may 
be  employed.  Two  sharp  needles  of  platinum,  steel,  or  soft 
iron  are  prepared  by  coating  them,  except  the  points,  with 
gutta-percha,  varnish,  or  gum.  Many  practitioners'^  connect 
one  needle  with  the  positive,  and  the  other  with  the  negative, 
pole  of  the  battery.  Dujardin-Beaumetz,^  Dreschfeld,*  and 
others,  prefer  to  attach  them  only  to  the  positive  pole  ;  the 
circuit  being  completed  by  connecting  the  negative  pole  with  a 
metallic  plate  or  moistened  sponge  applied  either  near  the 
aneurism  or  on  another  part  of  the  body.  Pain  may  be  dimin- 
ished by  freezing  the  sMn  over  the  aneurism,  with  pounded  ice 
or  ether  spray.  Then  the  needles  may  be  plunged  into  the 
tumor,  and  the  electrical  current  may  be  gradually  increased, 
and  continued  for  twenty  or  thirty  minutes  at  a  time.  The 
operation  may  be  repeated  after  an  interval  of  weeks  or  months. 
The  prevailing  theory  of  the  beneficial  action  of  electricity  is 
that  it  produces  or  promotes  coagulation  of  blood  within  the 
aneurismal  sac. 

Petit  ^  has  collected  114  cases  of  galvano-puncture  for  thoracic 
aneurism,  in  which  amelioration  was  effected  in  69  instances. 
In  61  cases  more  or  less  aggravation  of  the  symptoms  resulted. 
The  greater  number  of  patients  obtained  by  its  means  relief  or 
diminution  of  pain  and  dyspnoea,  with  increase  of  appetite  and 
ability  to  sleep.  While  scarcely  any  actual  cures  seem  to  have 
been  effected  by  this  method  of  treatment,  the  amount  of  bene- 
fit appears  to  be  quite  sufficient  to  justify  it  in  cases  which  con- 
tinue to  grow  worse,  notwithstanding  the  employment  of  iodide 
of  potassium  and  rest  through  a  long  period. 

Dr.  Headland  Greenhow  reports'*  the  entire  cure  of  a  case 
occurring  in  an  able-bodied  seaman,  aged  28,  by  pressure  (con- 
tinued, at  intervals,  for  three  or  four  hours  at  a  time)  with  Lis- 
ter's tourniquet  upon  the  aorta  above  the  tumor.  Drs.  Murray, 
Moxon,  and  Durham  (in  1864  and  1872)  have  reported  two  other 
successful  cases,  under  the  same  treatment.  Dr.  S.  P.  Speer  had 
two  recoveries  under  gallic  acid  internally,  with  iron.' 

AOETIC   STENOSIS. 

This  term,  meaning  contraction  of  the  aorta,  applies  strictly  to 
cases  of  very  rare  occurrence,  unless  amongst  still-born  children, 

iL'Union  Medicale,  Aug.  1, 1880.  2  Pepper,  N.  Y.  Med.  Record,  Nov.  13,  1880. 

3  Bulletin  Gen.  de  Therapeutique,  July  15,  1880.  ' 

4 Lancet,  Oct.  12,  1878.  5  L'Union  Medicale,  Aug.  21,  1880. 

6  British  Med.  Journ.,  June  14,  1873.     ?  Med.  and  Surg.  Reporter,  March  28, 1874. 


STOMATITIS.  257 

or  those  dying  early  in  life.  Occasionally,  however,  instances 
are  met  with,  cspccisilly  in  subjects  under  age,  presenting  the 
following  signs  :  a  murmur  in  t!ic  aortic  region,  and  extending 
from  this  more  or  less  distinctly  over  the  chest ;  feehleness  or 
absence  of  pulsation  in  the  arteries  of  the  lower  extremities ; 
imperfect  growth  of  the  extremities  and  of  the  genital  organs  ; 
dilatation  of  the  intercostal  and  other  superficial  arteries ;  ten- 
dency to  passive  congestions,  for  instance,  of  the  hands,  feet, 
lips,  and  ears. 

Such  persons  are  not  likely  to  attain  to  long  life ;  but  examyjles 
have  been  known  of  their  surviving  for  a  number  of  years  after 
the  evidences  of  this  malformation  liave  been  discovered.' 

The  oriijin  of  aortic  stenosis  may  be  a  simple  defect  of  develop- 
ment ;  or  the  organization  of  a  c?oi,  or  thrombus,  during  foetal  or 
infantile  life ;  or  an  ivflammation  of  the  aorta,  followed  by  its 
constriction,  or  partial  obstruction  by  bands  of  lymph. 

No  treatment  can  exert  any  influence  upon  a  true  aortic  steno- 
sis. Warning  must  be  given  to  the  patient  that  his  constitution 
unfits  him  for  great  or  sudden  exertion,  or  strong  excitement. 

AFFECTIONS  OF  THE  ORGANS  OF  DIGESTION. 

STOMATITIS. 

Defillition. — Inflammatory  disease  of  the  mouth. 

Varieties. — 1.  Simple  stomatitis.  2.  Aphtha.  3.  Thrush.  4. 
Inflamed  ulcer  or  canerum  oris.  .5.  Gangrene  of  the  mouth. 
6.  Mercurial  sore  mouth  or  salivation.  7.  Nursing  sore  mouth. 
8.  Scorbutic  disease  of  the  mouth. 

Simple  Stomatitis.—  From  taking  very  hot  or  corrosive  liquids 
into  the  mouth,  it  may  become  inflamed  ;  this  condition  being 
shown  by  redness,  swelling,  soreness  and  heat  of  the  tongue, 
gums,  lining  membrane  of  the  cheeks,  palate,  and  fauces.  Cor- 
rosives (as  sulphuric  acid  or  creasote)  may  whiten  the  mucous 
membrane  superficially. 

The  course  of  such  an  affection  is  generally  simple  and  brief- 
recovering  in  a  few  days  under  mild  treatment.  Glossitis,  how- 
ever, or  inflammation  of  the  tongue,  may  be  more  obstinate  and 
serious.  I  have  seen  the  tongue  so  swollen  as  to  protrude  from 
the  mouth  for  more  than  a  week,  too  large  to  return. 

Slight  ulcerations  and  fissures  often  occur  in  simple  stomatitis, 
increasing  the  soreness  and  pain ;  and  increase  in  the  flow  of 
saliva  is  common. 

Treatment. — In  the  beginning,  holding  ice,  iced  gum-water  or 
flaxseed-tea  frequently  in  the  mouth,  or,  if  a  corrosive  agent  be 
the  cause,  almond  oil  or  dilute  glycerin  [F.  .50],  will  soothe  the 
irritation.  In  violent  glossitis,  leeches  may  be  applied  to  the 
swollen  tongue  ;  even  free  incisions  may  be  called  for  to  relieve 
its  swelling  ;  later,  solution  of  alum  (5ij  in  f^vj  of  water)  or  sul- 
phate of  zinc  (gr.  j  in  fgj)  may  be  used  as  a  wash.  Remember 
that  such  articles  ought  not  to  remain  in  contact  with  the  teeth, 
the  enamel  of  which  they  may  impair. 

1  r:.  F.  lugalls,  N.  Y.  Med.  Record,  Sept.  4,  1880,  p.  255. 


258  DISEASES   OF  ORGANS   OF   DIGESTION. 

Follicular  iiiflainmation  of  the  mouth  is  recognized  by  small 
red  elevations  over  the  tongue,  soft  palate,  etc.  This  is  common 
in  infants  during  dentition  ;  as  well  as  in  adults  of  deficient  gen- 
eral health.     It  requires  no  specialty  of  treatment. 

Aphthae, — These  are  small  ulcers,  with  whitish  surfaces,  follow- 
ing a  vesicular  eruptive  inflammation  of  the  mouth.  The  ves- 
icles are  small,  round  or  oval,  of  a  pearly  appearance,  and  con- 
tain serum.'  They  break  in  a  few  days,  leaving  a  sore  white 
ulcer,  with  redness  around  it.  They  may  be  scattered  or  con- 
fluent. Fever  may  attend  the  latter,  with  disorder  of  the 
stomach.  Though  not  common  in  the  earliest  infancy,  children 
sometimes  liave  this  disease,  but  less  often  than  adults.  Decaj'ed 
teeth  may  produce  it.  On  the  whole,  it  is  to  be  considered  rare. 
Its  duration  is  generally  a  week  or  two,  but  confluent  cases  may 
last  a  month,  and  have  occasionally  been  fatal. 

Treatment. — The  constitutional  condition  may  require  cooling 
laxatives  or  saline  diaphoretics,  and  gastric  irritation  may  call 
for  antacids,  as  bicarbonate  of  sodium  or  magnesium.  Chlorate 
of  potassium  should  be  given,  5  to  20  grains  four  times  daily. 
Locally,  at  first,  flaxseed  tea  or  gum-water,  or  a  solution  of 
glycerin  in  rose-water,  may  be  frequently  applied.  When  ulcera- 
tion occurs,  a  powder,  consisting  of  equal  parts  of  prepared 
chalk  and  pulverized  gum  arable  [F.  51],  may  be  dusted  or  laid 
over  each  of  the  ulcers,  several  times  a  day.  Some  prefer  a 
mixture  of  glycerin  and  prepared  chalk,  of  the  consistence  of  a 
soft  paste.  A  wash  of  borax,  myrrh  [F.  52] ,  alum,  sulphate  of 
zinc  [F.  53],  or  acetate  of  lead,  may  also  be  applied.  If  the 
ulcer  prove  severe  or  obstinate,  strong  solutions  of  sulphate  of 
zinc  (15  grs.  in  fgj  of  water)  or  nitrate  of  silver  (20  grs.  in  foj), 
or  solid  sulphate  of  copper,  may  be  used  to  toudh  the  ulcerated 
surface  every  day  or  two. 

Thrush:  Muguet. — This  is  much  more  frequent  in  infancy. 
Its  peculiarity  is,  the  occurrence,  after  a  day  or  two  of  diffused 
inflammation,  of  a  number  of  small  whitish  points  within  the 
mouth,  which  coalesce  and  form  patches  of  a  whitish  curd-like 
exudation  (often  confounded  with  aphthce).  In  bad  cases  it  may 
become  brownish.  This  may  fall  off  and  be  renewed,  more  than 
once.  The  mouth  is  hot,  the  stomach  disordered ;  vomiting  and 
diarrhoea  may  occur,  with  some  fever.  The  attack  lasts  from 
one  to  two  or  three  or  more  weeks ;  being  seldom  dangerous 
except  in  children  otherwise  in  poor  health.  It  sometimes 
attacks  adults. 

Nature. — The  specific  nature  of  the  curd-like  exudation  appears 
to  be  connected  with  a  microphytic  (minute  vegetative)  growth, 
to  which  the  name  of  oidium  albicans  has  been  given. 

Treatment. — Experience  favors  the  internal  administration  of 
chlorate  of  potassium  [F.  54]  in  all  severe  forms  of  sore  mouth. 
In  the  absence  of  a  rationale  by  which  its  special  applications 
might  be  definable,  I  would  employ  it  in  thrush  as  well  as  in 
aphthae,  etc,  A  child  under  five  years  of  age  may  take  from  one 
to  five  grains  of  the  chlorate,  in  solution,  several  times  daily. 

iDr.  J.  Worms  asserts  the  discharge  of  aphthous  vesicles  and  ulcers  to  he  sebaceous. 
He,  therefore,  regards  apbthse  as  a  sort  of  acne  of  the  mucous  membrane. 


STOMATITIS.  259 

As  a  laxative,  magnesia  wiJl  be  suitable.  Feeble  cases  may 
require  quinine,  beef-tea,  whisky  and  milk,  in  quantities  propor- 
tioned to  condition  and  age. 

Locally,  at  first,  we  may  use  flaxseed  or  gum  arable  emulsion — 
then  glycerin  and  rose-water  (one  part  to  four  or  five),  borax  in 
solution  ("2  drachms  in  4  ounces)  or  in  powder,  equal  parts  witli 
sugar— and  later,  tincture  of  myrrh  in  water  (fS^s  in  fgij), 
alum  in  solution,  or  sulphate  of  zinc,  or  muriatic  acid  with  honey 
and  water  (acid,  hydrochlor.  ^j,  mellis  velsyrupi  f5J,  aquai  fgij) ; 
the  latter  being  applied  carefully  with  a  camel's-hair  pencil,  occa- 
sionally. 

Cancrum  Oris.— Canker  of  the  mouth  is  characteristically  ulcer- 
ative, from  the  commencement.  It  begins  on  the  cheeks,  gums, 
or  lining  of  the  lips ;  but  may  reach  the  fauces.  The  ulcer  is 
grayish  or  j^ellowish-white,  with  an  inflamed  border  and  environs ; 
the  cheek  may  swell  from  it  externally.  It  is  quite  painful.  Saliva 
flows  freely,  and  the  odor  of  the  breath  is  offensive.  Fever  is 
often  present.  The  complaint  may  last  for  several  weeks  or  even 
months ;  but  it  is  almost  never  fatal.  It  is  most  common  in 
children,  from  two  to  six  years  of  age. 

Treatment. — Besides  general  measures,  adapted  to  the  condition 
ofthejjdtient,  the  same  local  applications,  mentioned  as  appropriate 
in  dificrent  forms  of  sore  mouth,  may  be  used.  Direct  touching 
of  the  ulcer  with  a  strong  solution  of  sulphate  of  zinc  (gr.  xv  vel 
XX  in  fgj),  or  with  the  solid  bluestone  (sulphate  of  copper)  twice 
daily,  will  do  the  most  for  its  cure ;  especially  with  the  interme- 
diate "  dressing"  of  powdered  chalk  and  gum  arable,  and  occa- 
sional washing  with  glycerin  and  rose-water. 

Gangraena  Oris. — Extreme  inflammation  or  ulceration,  in  the 
mouth  as  elsewhere,  may  end  in  gangrene  ;  but  this  affection  is 
peculiar,  and  may  be  unconnected  with  any  severe  inflammation. 

A  morbid  state  of  the  system  seems  to  predispose  to  it.  It 
occurs  mostly  in  children,  but  has  been  met  with  in  adults. 

There  is,  at  first,  an  ash-colored  ulcer,  most  often  on  the  gums, 
or  inside  of  the  cheek.  If  the  latter,  it  is  accompanied  by  swelling. 
Spreading,  it  assumes  a  sloughing  character  ;  the  breath  grows 
fetid ;  acrid  fluid  is  discharged,  with  copious  salivation ;  other 
ulcerations  are  formed,  the  bones  of  the  face  are  affected  with 
necrosis,  and  the  teeth  fall  out.  Penetrating  the  cheek,  mortifi- 
cation may  go  on  rapidly,  reaching  sometimes  even  the  ethmoid 
bone.  Low  fever  and  prostration  attend  these  local  changes ; 
later,  diarrhcea,  colliquative  perspirations,  and  death.  The  only 
well-marked  promotive  causes  of  this  very  serious  disease  are, 
bad  air  (especially  crowd-poison)  and  insufficiency  of  food.  When 
treated  early,  it  is  often  quite  manageable  ;  but  after  extensive 
sloughing  has  occurred,  the  prognosis  is  bad. 

Treatment. — Early,  I  should  always  try  the  chlorate  of  potas- 
sium. Quinine  and  tincture  of  chloride  of  iron  [F.  56]  will  be  re- 
quired on  account  of  the  tendency  to  prostration.  Beef-tea  and 
wine  whey,  or  brandy  or  whisky  punch,  pro  re  nata,  are  called 
for,  by  the  same  indication. 

To  the  part,  at  first,  the  astringent  lotions,  mentioned  already, 
may  be  applied.     When  the  gangrenous  condition  becomes  pro- 


260  DISEASES  OF  OEGANS  OF  DIGESTION. 

nounced,  a  solution  of  liquor  sodse  chlorinat.  in  glycerin  (f^j  in 
fgij)  may  be  applied  frequently.  Solution  of  ereasote  in  glycerin, 
or  in  water  (gtt.  iij  togtt.  xx  infgj)  may  meet  the  same  purpose  ; 
or  permanganate  of  potassium  (gr.  x  in  fgj) ;  or  chloride  of  zinc 
(gr.  j  in  fgj) ;  or  sulphite  of  sodium  (5j  in  fgj)  ;  or  bromine  (5ss 
in  fgij). 

Mercurial  Sore  Month. — Salivation  is  made  known  in  its 
approach,  by  a  "  coppery  "  taste,  soreness  of  the  gums,  tender- 
ness of  the  teeth  when  pressed  together,  with  redness  and  swell- 
ing of  the  gums,  and  a  broad  white  line  just  beyond  their  edge. 
The  tongue  also  may  swell.  The  flow  of  saliva  increases  greatly  ; 
the  cheeks  and  even  throat  may  grow  sore  and  painful ;  the 
breath  offensive.  Ulceration  of  the  gums  takes  place  in  severe 
cases,  with  loss  of  the  teeth.  Even  sloughing  may  follow, 
approaching  the  state  of  things  in  gangrcena  oris.  Difficulty  of 
swallowing  may  be  so  great  as  to  threaten  starvation  ;  and  irri- 
tative fever  may  result  from  the  local  disorder. 

Treatment. — Moderate  salivation  will  always  pass  away  in  a 
few  days,  spontaneously.  A  good  mouth-wash  for  it  is  brandy 
or  whisky  and  water,  one  part  of  the  former  to  four  of  the  latter  ; 
alum  may  be  added  to  it  [F.  59] ,  or  a  little  tincture  of  myrrh. 
Ulcers  or  sloughs  should  be  treated  as  in  other  varieties  of 
stomatitis. 

Opium  may  be  called  for,  at  least  at  night  (e.  g. ,  Dover's  powder 
10  grains  at  bedtime),  by  the  distress  of  the  system.  Milk  diet, 
or  some  other  liquid  nourishment,  must  be  given  during  the  diffi- 
culty of  deglutition.  In  good  practice,  at  the  present  day,  no 
physician  ever  seriously  salivates  a  patient. 

BTurses'  Sore  Moutli. — Women  who  suckle  children,  and  some- 
times those  who  are  advanced  in  pregnancy,  are  liable  to  ulcera- 
tive stomatitis.  It  begins  with  small,  hard,  painful  swellings  on 
the  tongue  and  cheeks,  which  ulcerate  and  are  attended  by  a  great 
deal  of  local,  and  sometimes  constitutional  irritation.  When  the 
infant  is  weaned,  the  affection  subsides  soon. 

Treatment. — Chlorate  of  potassium  has  in  this  complaint  a  spe- 
cial curative  power.  20  grains  of  it  may  be  given  three  or  four 
times  daily.  Iron,  quinine,  etc.,  and  full  nourishment,  may  be 
required  in  subjects  of  obvious  debility.  Local  treatment,  such 
as  has  been  given  for  cancrum  oris,  etc.,  will  also  have  its  utility. 

Scorhutic  mouth  affection  will  be  dealt  with  in  another  part  of 
the  book — under  Scurvy. 

TONSILLITIS. 

When  severe,  this  is  commonly  known  as  quinsy.  Soreness  of 
the  throat  in  swallowing,  with  pain  or  swelling  of  one  or  both 
tonsils,  and  fever,  are  its  symptoms.  Unless  relieved  in  a  few 
days,  the  pain  becomes  very  constant  and  throbbing,  dysphagia 
is  extreme,  and,  when  the  patient  begins  to  be  seriously  alarmed, 
a  tonsillar  abscess  breaks  or  is  o^Dened  by  the  physician,  and 
recovery  soon  follows.  In  a  very  few  instances,  bleeding  after  the 
incision  (or  after  excision  of  the  gland)  without  wounding  the 
artery,  has  been  troublesome,  and  even  dangerous  to  life.     We 


PHARYNGITIS.  261 

must  supposo  hrvmnpMlia  (constitutional  predisposition  to  hem- 
orrhage) to  account  for  sucli  events. 

Treatment. — A  dose  of  citrate  or  sulphate  of  magnesium,  or 
other  cooling  aperient,  should  be  given  the  first  day.  Then,  wine 
of  ipecac,  twenty  drops  every  three  hours,  with  frequent  draughts 
of  flaxseed  tea  or  flaxseed  lemonade.  If  the  swelling,  heat,  and 
pain  of  the  throat  are  great,  ai)pl}^  (in  an  adult  j  from  20  to  30 
American  leeches  to  it.  Then,  or  instead,  in  mild  cases  or  feeble 
subjects,  poultice  with  flaxseed  meal,  to  which  lard  and  laudanum 
have  been  added  ;  bathing,  when  the  poultice  is  changed,  with 
liniment  of  ammonia,  or  soap  liniment  to  which  aqua  ammonite 
has  been  added.  If  still  severe,  and  not  certainly  suppurating,  a 
small  blister  may  be  applied,  or  the  part  may  be  painted  with 
tincture  of  iodine.  When  an  abscess  is  evidently  forming,  poul- 
tices will  be  better,  until  it  is  ready  to  open  from  within. 

Lancing  the  suppurated  tonsil  requires  care  not  to  wound  the 
internal  carotid  artery.  The  point  of  the  lancet  should  be  directed 
towards  the  middle,  not  to  the  outside  of  the  throat. 

ISTot  unfrequently,  especially  in  children,  repeated  attacks  of 
non-suppurating  inflammation  of  the  tonsils  will  leave  them  incon- 
veniently enlarged.  Sometimes  persevering  use  of  astringent  gar- 
gles, or  touching  daily  with  strong  solution  of  tannin  or  nitrate  of 
silver,  will  make  them  shrink  to  the  normal  size.  If  not,  excision 
of  a  part  of  the  tonsil  may  be  proper.  With  Fahnestock's,  or  any 
other  guillotining  instrument,  the  operation  is  easy  and  safe  ;  at 
all  events,  if  it  be  not  attempted  to  remove  the  whole  gland,  which 
is  not  necessary.  Should  hemorrhage  occur,  it  may  be  suppressed 
by  applying  to  the  part,  on  the  end  of  a  short  stick,  a  pad  of  lint 
which  has  been  soaked  in  solution  of  persulphate,  or  tincture  of 
perchloride,  of  iron  ;  aided  by  the  application  of  ice  to  the  outside 
of  the  thi'oat.'  Ehrmann  has  reported  a  case  in  which  (without 
any  operation)  the  spontaneous  rupture  of  a  tonsillar  abscess  was 
followed  by  hemorrhage  so  severe  as  to  require  ligature  of  the 
carotid  artery.^ 

PHARYNGITIS. 

Slight  sore  throat  is  among  the  commonest  of  affections,  requir- 
ing for  its  treatment  only  mild  gargles  (as  alum  in  flaxseed  or  sage 
tea),  demulcents  (flaxseed  or  gum  arabic  or  slippery  elm  infusion), 
or  laudanum  and  water,  one  part  to  eight,  fomentation  with  vola- 
tile liniment  or  spirits  of  turpentine,  and  a  dose  of  some  saline 
cathartic,  with  slo2)  diet.  With  children  who  cannot  gargle,  finely 
powdered  alum  may  be  blown  into  the  fauces  and  throat,  through 
a  tube  or  quill,  more  readily  than  in  any  other  way. 

Chronic  pharyngitis  is  often  a  much  more  troublesome,  though 
not  dangerous  disorder.  The  mucous  membrane  becomes  perma- 
nently hypersemic,  almost  granulated  ;  with  either  abnormal  dry- 
ness or  a  thickened  secretion ;  and  constant  soreness.  In  the 
treatment  of  this,  all  the  difterent  astringent,  demulcent,  and 
alterative  applications  may  be  tried — sometimes  with  little  suc- 

1  Lidon  reports  a  case  where,  from  abnormal  tendency  to  bleeding,  the  hemorrhage 
obliged  him  to  tie  the  carotid  artery.    This  must  be  a  very  rare  accident. 

2  Centralblatt  fur  Chirurg.,  No.  34, 1379. 


262  DISEASES   OF   ORGANS   OF   DIGESTION. 

cess.  When  nitrate  of  silver,  tannin  [F.  60] ,  sulphuric  and  mu- 
riatic acids,  sulphate  of  zinc  and  acetate  of  lead  have  been  found 
to  fail,  it  may  happen  that  ice,  or  gargling  frequently  with  ice- 
water,  will  prove  more  useful. 

Counter-irritation,  with  repeated  small  blisters,  tincture  of 
iodine,  or  croton-oil,  is  always  a  suitable  and  important  part  of  the 
treatment  of  chronic  inflammation  of  the  throat. 

Ulcerated  Sore-throat. — This  may  be  idiopathic,  syphilitic,  or 
tuberculous.     The  second  is  most  common. 

The  treatment  in  the  first  variety  consists  in  the  local  applica- 
tion of  bluestone  or,  lightly  touched,  solid  nitrate  of  silver  to  the 
ulcers,  if  within  reach.  The  syphilitic  will  require  also  iodide  of 
potassium  [F.  61]  internally  (gr.  v  velxter  die);  the  tuberculous, 
tonics,  generous  diet,  and  cod-liver  oil.  Iodoform,  in  powder 
(applied  with  a  moistened  camel's-hair  pencil),  is  an  excellent 
local  detergent  and  alterative  for  ulcerated  sore  throat. 

RETEOPHARYNGEAL  ABSCESS. 

This  most  often  follows  fever  as  a  sequela  ;  but  it  is  altogether 
rare ;  least  so  in  children,  in  whom,  however,  it  is  liable  to  be 
overlooked.  Of  144  cases  reported  by  Bokai,  of  Pesth,  134 
occurred  under  four  j^ears  of  age.  Of  these,  32  were  scrofulous, 
and  10  rachitic.  The  affection  is  shown  to  the  careful  observer 
by  dysphagia  and  dyspncBa,  much  increased  by  the  recumbent 
posture  ;  yet  not,  as  in  croup,  increasing  rapidly  from  day  to  day, 
or  disappearing  in  a  short  time.  There  is  also  stiffness  of  the 
neck,  and  swelling  on  one  or  both  sides  of  it.  In  such  circum- 
stances a  finger  passed  over  the  tongue  into  the  pharynx  may 
find  a  firm  projecting  tumor  occupying  its  posterior  and  lateral 
walls.  It  may  prove  fatal  by  asphyxia,  or  by  preventing  the 
patient  from  swallowing  food.  When  diagnosticated  in  time,  the 
matter  may  be  let  out  by  opening  the  abscess  with  a  lancet 
through  the  pharyngeal  wall.  In  an  adult,  a  trocar  will  be  safer, 
the  head  being  rapidly  bent  forward  after  the  operation,  to  pre- 
vent suffocation  by  the  discharge  suddenly  entering  the  air-pass- 
ages in  breathing.^  If  there  be  doubt  as  to  the  nature  of  the 
tumor,  aspiration  (Dieulafoy)  will  aid  the  diagnosis.  . 

STRICTURE  OF  THE  (ESOPHAGUS. 

This  is  uncommon.  Its  principal  causes  are,  if  structural,  cor- 
rosive poisons,  swallowed  ;  or  ulceration  of  the  throat,  involving 
the  oesophagus,  and  contracting  upon  cicatrization.  Functional 
stricture  may  be  spasmodic,  as  in  hysteria.  Dysphagia,  not  other- 
wise accounted  for,  and  obviously  low  down  in  its  seat,  or  the 
rejection  of  food  partly  swallowed,  may  lead  to  a  suspicion  of 
stricture  ;  and  examination  with  a  bougie  will  fix  the  diagnosis. 
For  the  structural  affection  I  know  of  no  appropriate  treatment 
except  dilatation  with  bougies  made  for  the  purpose,  applied  for 
a  short  period,  oiled,  once  or  more  daily.  Elias,^  in  one  case,  suc- 
cessfuUyperformedgastrotomy ;  making anartificial gastric  fistula. 

1  Aberlin,  Schmidt's  Jabrbucher,  No.  5,  1872, 

2  Deutsche  Med.  Wochens.,  No.  25, 1880. 


GASTRITIS.  263 


GASTRITIS. 


Simple  gastritis,  in  ah  acute  form,  is  very  rare.  I  have  mot 
■with  but  one  case  of  it,  in  a  woman  who  was  kicked  over  the 
stomach  by  her  husband.  Corrosive  poisons  almost  always  in- 
volve the  intestinal  tube  with  the  stomach.  The  most  common 
form  of  "idiopathic"  r^astric  inflammation  is  "gastro-hepatic 
catarrh, "  or  "a  biUous  attack, "  in  which  the  stomach, duodenum, 
and  liver  are  all  somewhat  involved. 

Signs  of  stomachic  inflammation  are,  epigastric  pain  and  ten- 
derness on  pressure,  rejection  of  all  food  and  drink,  jactitation, 
and  fever ;  the  pulse,  however,  being  kept  down  by  the  impres- 
sion made  upon  the  circulation  by  constant  nausea. 

Post-mortem  evidences  of  gastritis  are — redness,  browner  or 
deeper  and  more  livid  than  natural,  and  dotted,  stellated,  or 
arborescent,  rather  than  difiused ;  moreover,  not  confined  to 
dependent  parts ;  enlargement  of  blood-vessels ;  in  acute  cases, 
softening  of  the  mucous  membrane ;  in  more  lengthened  ones, 
either  softening  or  hardening  and  thickening ;  abundance  of 
thickened  mucus  ;  rarely,  coagulable  lymph  ;  almost  never,  pus. 

Gastro-hepatic  catarrh  (Chambers)  may  follow  any  of  the 
causes  of  indigestion,  or  exposure  to  cold  and  wet.  There  is 
nausea,  or  vomiting  of  greenish-yellow  fluid,  generally  not  copi- 
ous, but  very  acrid ;  headache  and  dizziness ;  constipation  of 
the  bowels,  and  fever.  In  the  treatment  of  this,  magnesia  is  a 
good  quieting  stomachic  and  cathartic ;  many  patients  will  be 
relieved  as  soon  by  a  bottle  of  solution  of  citrate  of  magnesium. 
Ice,  melted  in  the  mouth  and  swallowed  slowly,  will  give  com- 
fort. Rest  and  abstinence  from  food  as  nearly  as  possible  may, 
with  the  above,  generally  complete  the  cure  in  two  or  three,  or 
not  mau}^  more  days. 

The  best  preventive  or  abortive  of  a  "bilious  attack"  is  blue 
pill^  timely  administered.  Let  the  first  nausea,  constipation,  and 
headache  be  met  by  giving  at  bedtime  two  or  three  grains  of  blue 
mass  in  pill  (the  '■'■lang  syne''''  portion  was  from  six  to  twenty), 
followed  in  the  morning  by  a  teaspoonful  or  two  of  Husband's 
magnesia.  If  the  bowels  are  free,  bicarbonate  of  sodium  may  be 
better  than  magnesia  ;  the  eighth  part  of  a  teaspoonful  at  a  dose. 
Chloride  of  ammonium,  in  15  or  20  grain  doses,  proves  the  best 
medicine  for  some  such  cases. 

Sick  headache  is  usually  a  modification  of  the  above,  the 
sympathetic  cephalalgia  being  especially  severe.  In  some  per- 
sons it  is  periodic.  The  treatment  above  mentioned  for  gastro- 
hepatic  catarrh,  with  rest  in  bed,  will  be  adapted  to  a  majority 
of  cases  of  it.  Oil  of  turpentine^  in  moderate  doses,  has  been  said 
(W.  Begbie)  to  be  remedial  for  it.  Dr.  Kennion'  advises  a  solu- 
tion of  bisulphide  of  carbon,  applied  to  the  temples  or  behind  the 
ear,  for  a  short  time.  Citrate  of  caffein  (3  to  5  grains  at  a  dose) 
is  highly  recommended  by  several  practitioners. 

Acute  softening  of  the  stomach  is  described  by  a  few  French 
and  other  writers,  as  a  rapidly  prostrating  and  dangerous  aftec- 
tiou  in  children,  sometimes  epidemic.     Its  symptoms  are  said 

1  Brit.  Med.  Journal,  June  13,  1868. 


264        DISEASES   OF  ORGANS   OF  DIGESTION. 

to  be,  at  first,  those  of  simple  gastritis ;  then,  with  or  without 
diarrhoea,  great  agitation,  prostration,  want  of  sleep,  insensibility 
— and  death  in  one  or  two  weeks  from  exhaustion.  I  have  never 
met  with  any  such  case.  An  irregular  fever  with  gastric  irrita- 
tion (gastric  fever  or  infantile  remittent)  once  had  a  regular 
place  in  the  nosological  catalogue  among  fevers.  It  appears  to 
me  to  be  scarcely  uniform  enough  for  so  special  a  designation  or 
consideration. 

Acute  dilatation  of  the  stomacli  has  been  reported  upon  espe- 
cially by  Dr.  C.  Hilton  Pagge.^  It  is  very  rare.  Its  symptoms 
are  those  of  severe  abdominal  disease;  particularly,  profuse 
vomiting.  As  physical  signs,  we  have  rapidly  increasing,  unsym- 
metrical  distention  of  the  abdomen  (largest  on  the  left  side),  and 
a  widely  extended  tympanitic  resonance  over  the  dilated  region. 
In  treatment,  evacuation  of  the  stomach  by  aid  of  the  stomach- 
pump  appears  to  be  indicated ;  with  continued  rest  to  the  organ, 
nourishment  being  afforded  by  enemata. 

Subacute  Gastritis  of  Childreii.— In  the  older  books  on  medi- 
cine, and  still  by  a  few  authors  (e.  g..  Dr.  F.  P.  Porcher,^  of 
Charleston,  S.  C. ),  this  has  been  called  gastric  remittent,  or  infan- 
tile remitteyxt  fever.  Its  symptoms  are  those  of  irritation  of  the 
stomach,  with  fever,  which  has  a  more  or  less  regular  daily 
remission,  almost  always  in  the  morning.  Its  treatment  requires 
rest,  diet  of  milk  with,  lime-water,  barley,  or  rice-water  ;  mild  laxative 
medicine's ;  gentle  abdominal  counter-irritation,  as  by  spice- 
plasters  ;  and  refrigerant  diaphoretics,  such  as  small  doses  of 
sweet  spirits  of  nitre,  acetate  of  ammonium,  etc.,  during  the 
febrile  exacerbations. 

CHEONIC  GASTEITIS. 

"While  the  same  doubt  as  to  the  pathological  correctness  of  the 
name  (indicating  inflammation)  exists  in  the  case  of  this  disease 
as  in  other  "chronic  inflammations"  (see  General  Pathology),  an 
affection  of  some  distinctness  of  character,  commonly  called  by 
the  above  title,  is  often  observed.  With  the  greatest  brevity,  we 
may  indicate  its  symptomatology  by  contrasting  it  with  that  of 
atonic  dyspepsia. 

In  Chronic  Gastritis.  In  Atonic  Dyspepsia. 

Much  epigastric  tenderness.  Little  orno  epigastric  tenderness. 

Pain  increased  by  active  exer-  Pain  not  increased  by  exercise, 

cise  or  stimulating  food.  lessened  by  stimulating  food. 

Vomiting  usually.  Vomiting  rarely. 

Eructation  of  gas  rarely.  Eructation  of  gas  commonly. 

Chronic  gastritis  is  apt  to  be  obstinate,  but  not  dangerous  to 
hfe. 

Treatment. — Counter-irritation  over  the  epigastrium  by  re- 
peated vesication,  will  be  useful.  Internally,  nitrate  of  silver  [P. 
62] ,  in  pill,  beginning  with  gr.  J,  with  gr.  I  of  opium,  and  increas- 
ing in  a  few  days  or  a  week,  gradually  rising  to  1  gr.  thrice  daily, 
with  a  proportionate  quantity  of  opium,  I  believe,  upon  experi- 

1  Guy's  Hospital  Reports,  vol.  xviii.,  1873. 

s  Am.  Jour,  of  Med.  Sciences,  January,  1881,  p.  46. 


ANTI-EMETIC    REMEDIES.  265 

ence,  to  be  the  most  valuable  "medicine.  Subnitrate  of  bismuth 
[F.  03]  is  for  the  same  condition  lauded  by  some.  Most  impor- 
tant is  a  hland-dk't;  lime-water  and  milk,  arrowroot,  tapioca, 
sago,  jellies,  cracker  soaked  in  ice-water,  etc.,  in  small  quantities 
at  short  intervals.  Ice  will  often  quench  thirst  to  better  advan- 
tage, without  disturbing  the  stomach,  than  water.  The  skim- 
hiilk  regimen  (Karell)  may  be  adapted  to  some  cases  of  this 
disease.^  Feeding  by  the  rectum  is  indispensable  in  bad  cases; 
beef-tea,  defibrinated  blood,  eggs,  milk,  arrowroot,  fruit,  jellies, 
etc.,  may  be  thus  administered. 

ANTI-EMETIC  REMEDIES. 

Yomiting  is  so  frequent  and  troublesome  a  symptom,  in  many 
diseases  besides  inflammation  of  the  stomach,  as  to  demand 
much  practical  study  from  the  physician.  For  this  reason, 
though  quite  in  deviation  from  systematic  routine,  I  here  intro- 
duce an  enumeration  of  the  most  available  medicines  used  for 
the  relief  of  the  symptom  of  vomiting — the  selection  among  them 
depending  upon  the  judgment  of  the  practitioner  as  to  the  real 
cause  of  that  symptom.  At  the  same  time  it  is  clear  that  many 
of  these  remedies  prove  useful  for  vomiting  when  produced  by 
very  diflerent  and  almost  opposite  causes  ;  the  symptom,  as  such, 
rationally  demanding  medication  when  we  are  uncertain  or  in 
search  of  its  cause. 

Ice.  Cinnamon-water. 

Lime-water.  Infusion  of  cloves. 

Mineral  water.  Hydrocyanic  acid. 

Elfervescing  draught.  Chloroform. 

Champagne.  Hydrate  of  chloral. 

Brandy.  Nitrate  of  silver. 

Paregoric.  Oxide  of  silver. 

Solution  of  morphia.  Subnitrate  of  bismuth. 

Aromatic  spirit  of  ammonia.       Oxalate  of  cerium. 
Comp.  tinct.  of  cardamom.  Enema  of  laudanum. 

Comp.  sp.  of  lavender.  Spice  poultice. 

Bicarbonate  of  potassium.  Sinapism.     Belladonna  plaster. 

Bicarbonate  of  sodium.  Blister  ;  surface  being  dressed 

Magnesia.  with  acetate  of  morphia  (gr. 

Camphor.  ij,  with  gum  acacise,  gr.  x). 

Calomel,  small  doses.  Ice-bag  to  the  spine. 

Blue  pill.  Hypodermic   injection   of  mor- 

Creasote.  pliia. 

[See  F.  64,  65,  66,  67,  68,  69,  70.] 

For  sea-sickness,  the  ice-bag  to  the  spine  is  said  to  be  sometimes 
remedial.  In  my  own  experience  of  this  affection,  iced  efferves- 
cent (carbonic  acid)  water  has  given  more  relief  than  anything 
else.  Hydrate  of  chloral  internally,  inhalation  of  nitrite  of  amyl 
(C.  Clapham,  Western  Lancet,  June,  1876),  3  drops  at  once,  and 
morphia  by  hypodermic  injection  over  the  epigastrium,  are  re- 
ported upon  favorably  in  its  treatment.  Surgeon  Cory,  of  the 
Australian  Mail  S.  S.  Co.,  found  nearly  always  successful,  a  mix- 

1  See  an  article  by  S.  W.  Mitchell,  M.  D.,  Thiladelphia  Med.  Times,  March  15,  1871. 
23 


266        DISEASES   OF   ORGANS  OF  DIGESTION. 

ture  of  bromide  of  potassium  and  hydrate  of  chloral,  taken  effer- 
vescing with  citrate  of  magnesium.  In  the  vomiting  of  pregnancy, 
bromide  of  potassium  has  been  found  very  serviceable. ^ 

tJLCER  OF  THE   STOMACH, 

This  serious  affection  is  rare  after  the  middle  of  life.  It  is  most 
often  met  with  in  feeble  systems,  especially  in  women, 

Sirmptoms. — Dull,  sickening  pain  in  the  stomach,  extending  to 
the  back,  with  localized  tenderness  on  pressure.  The  pain  is  in- 
creased by  motion,  and  by  food,  especially  by  hot  food,  or  by  sugar. 
Vomiting  occurs,  not  copious,  but  rather  frequent.  Vomiting  of 
blood  is  an  important  sign ;  it  is  impossible  to  be  certain  of  the 
existence  of  an  ulcer  in  the  stomach  without  it.  The  amount  of 
blood  thrown  up  at  once  may  be  very  small. 


Fig, 96 


I'i.  »,u{\. 


Ulcer  of  Stomach, 

It  is  often  difficult  to  diagnosticate  gastric  ulcer  from  chronic 
gastritis,  as  well  as  from  cancer,  caries  of  the  spine  and  aortic  aneu- 
rism. No  hsematemesis,  however,  is  met  with  in  the  first,  third,'- 
and  last ;  and  a  tumor,  at  some  period,  will  make  known  cancer. 
So  will  angular  deformity  demonstrate  spinal  caries. 

Perforation,  causing  peritonitis,  and  copious  hemorrhage,  are  the 
most  dangerous  terminations  of  gastric  ulcer.  The  signs  of  the 
former  are,  abdominal  swelling  and  diffused  pain,  with  collapse. 
One  instance  has  been  reported  (Chiari,  Viemifi,  1880)  of  the  rup- 
ture of  a  perforating  ulcer  of  the  stomach  into  the  left  ventricle 
of  the  heart. 

Treatment.— Bland  diet  is  very  important.   Arrowroot,  tapioca. 


1  Copeman's  method  of  treatment  of  the  vomiting  of  pregnancy  is,  to  dilate  the  cervix 
uteri  by  insertion  of  the  index  finger.  Dr.  Baldwin,  of  Ohio  (Ohio  Med.  Eecorder, 
Aug.,  1879),  reports  the  immediate  relief  of  an  obstinate  case  in  this  way.  _  Dr.  J.  S. 
Warren,  of  New  York,  has  had  great  success  with  Fowler's  solution  of  arsenic,  in  drop 
doses,  upon  an  empty  stomach. 

2  Unless  (improbably)  an  aortic  aneurism  should  communicate  with  the  stomach. 


CANCER    OF    THE    STOMACH. 


267 


sago,  corn-starch,  rice,  eggs,  and  linic-walcr  and  milk  arc  suital)lc. 
Beef  or   mutton    tea   (concentrated)  will   be   better  for  feeble 
patients  than  solid  food.     liectal  alimentation  will  sometimes  be 
indispensable,     to    aflbrd     the 
stomach  complete  rest.     Milk,  Fio.  97. 

eggs,  beef- tea,  defibrinated 
blood,  &c.,  will  answer;  but  it 
is  well  to  add  pepsin  to  such  ma- 
terials, so  as  to  approach  gastric 
digestion  as  nearly  as  possible. 
Nitrate  of  silver,  in  pill  with 
opium  [F.  02] ;  oxide  of  silver, 
in  1  or  2  grain  doses ;  iodoform 
in  one  grain  pills  ;  and  subni- 
trate  of  bismuth,  may  be  given 
with  the  hope  of  promoting 
cicatrization  of  the  ulcer. 
Opium  alone,  in  pill,  or  lauda- 
num, etc.,  or  conium  or  bella- 
donna, as  anodynes,  when  the 
pain  is  severe.  When  hemor- 
rhage is  threatening,^  ice,  crea- 
sote  ( ^  drop  to  2  dropsl,  tannic  or  gallic  acid,  acetate  of  lead,  oil 
of  turpentine  (small  doses),  tincture  of  chloride  of  iron,  ammonio- 
ferric  alum.  H3'podermic  injection  of  morphia  has  been  used 
with  advantage,  especially  to  check  vomiting,  in  this  affection. 


Perforating  Ulcer  of  Stomach. 


CANCER  OF  THE  STOMACH. 

Seirrhus  of  the  pylorus  is  the  most  common  form  ;  occasionally 
the  cardiac  orifice  is  the  seat  of  cancer.  It  is  a  frequent  form 
of  cancer;  of  9118  cases  of  cancer  in  Paris  in  four  years,  2303 
aftected  the  stomach.  The  usual  symptoms  are  pain,  in  rare  in- 
stances absent  or  nearly  so,  often  excruciating ;  epigastric  tender- 
ness, about  in  proportion  to  the  pain ;  vomiting  of  food,  mucus, 
and  "  coftee-grounds,"  or  mixed  blood  and  mucus,  almost  never 
pure  blood ;  acidity  or  other  symptoms  of  indigestion  ;  fetid 
breath  ;  decided  constipation  ;  emaciation,  and  cachectic,  almost 
jaundiced,  sallowuess  of  complexion  ;  sometimes  irritative  fever. 
The  diagnosis  is  made  nearly  certain  by  the  discovery  of  a  tumor  ; 
not  absolutely  so^as  the  tumor  may  be  fibroid,  and  not  malig- 
nant. 

Cancer  of  the  stomach  seldom  occurs  before  forty  years  of  age. 
Its  duration  averages  about  a  year  ;  it  seldom  reaches  two  years. 
The  i)atient  commonly  dies  by  slow  starvation,  the  stomach  be- 
coming incapable  of  digesting  and  transmitting  food. 

No  treatment  can  avail  for  the  cure  of  such  an  affection.  To 
nourish  by  concentrated  articles  of  diet,  as  beef-tea,  milk,  etc., 
and  to  allay  suffering  by  judicious  use  of  anodynes,  will  be  all  that 
we  can  do.  Kussmaul's  method  of  washing  out  the  stomach 
daily  with  a  solution  of  bicarbonate  of  sodium,  may  prove  an 


1  The  same  remedies  may  be  used  with  advantage  for  hsematemesis  from  other  causes. 


268  DISEASES  OF  ORGANS  OF   DIGESTION. 

important  measure  of  relief.  Dr.  J.  H.  Hutchinson^  has  reported 
a  case  in  which,  by  this  means,  vomiting  was  arrested,  and  the 
patient  was  enabled  to  take  and  retain  food.  Bectal  feeding  may 
sometimes  be  necessary. 

In  1881,  Billroth  removed  a  cancerous  pylorus  by  excision,  and 
the  patient  recovered.^  Soon  afterwards,  however,  he  repeated 
the  operation  on  two  other  patients,  both  of  whom  died.^ 

Chloral  may  be  particularly  recommended  for  trial ;  as,  in  some 
cases  of  cancer  of  other  parts  (uterus,  breast,  etc.),  Drs.  C.  Paul 
and  Martineau  have  found  hydrate  of  cliloral  to  exercise  an 
especially  favorable  influence.*  C'kian  turpentine  (Clay)  has  been 
put  (1880)  under  extensive  trial  for  various  forms  of  cancer.  The 
general  report  is  against  its  efficacy. 

Cancer  of  the  Duodenum^  Ccecum,  Bectunt,  a,nd  Omentum  are  much 
more  rarely  met  with.  Their  possibility  must  always  be  remem- 
bered in  considering  the  diagnosis  of  abdominal  tumors.^ 

DYSPEPSIA. 

Although  denied  a  special  place  in  nosology  by  recent  writers 
upon  diagnosis,  clinical  experience  calls  for  a  separate  recognition 
of  this  as  a  disease,  complex  in  its  pathology,  and  diverse  in  its 
symptoms.  Of  the  latter  only  a  very  general  account  can  here 
be  given. 

Symptoms. — The  patient /eeZs  his  stomach  all  the  time,  though 
not  nearly  always  with  pain.  Wli-en  the  latter  occurs,  it  is  often 
in  the  breast,  causing  suspicion  of  pectoral  disease.  Little  or  no 
tenderness  on  pressure  exists,  nor  is  there  much  nausea,  nor 
vomiting.  The  mouth  is  clammy,  or  has  a  sour  or  bitter  taste. 
The  complexion  is  more  or  less  sallow.  The  bowels  are  costive, 
and  stools  deficient  in  color.  Other  frequent  symptomatic  affec- 
tions are  cardialgia  (heartburn),  pyrosis  (waterbrash),  hypochon- 
driasis, palpitation  of  the  heart,  headache,  and  disorders  of  the 
senses,  as  diplopia  (seeing  double),  etc.  Dyspepsia  is  not  a 
dangerous,  but  is  frequently  a  very  obstinate  disease. 

Pathology. — The  functional  disturbances  above  enumerated 
have  their  seat,  more  or  less  prominently,  in  different  parts  of  the 
digestive  apparatus  ;  in  the  alimentary  mucous  membrane,  gland- 
ular, muscular,  or  ganglio-nervous  organs.  The  distressing  gastro- 
intestinal irritation,  cardialgia,  pyrosis,  etc.,  are  located  in  the 
mucous  membrane.  Defective  action  of  the  liver  and  enteric 
glands  produces  constipation,  with  its  consequences  ;  imperfect 
secretion  of  the  gastric  juice  and  pancreatic  fluid  impairs  the 
whole  process  of  digestion.     So  does  atony  of  the  muscular  coat  of 

1  Phil.  Med.  Times,  May  27,  1876.  Dr.  Hutchinson  found  that  the  best  way  to  effect 
this  was  by  the  use  of  Tkudiehum's  douche.  An  ordinary  stomach-tube  was  introduced 
into  the  stomach,  and,  by  means  of  a  rubber  pipe  attached  to  a  bottle  held  above  the 
patient's  head,  the  solution  passed  into  the  stomach  by  its  own  gravity.  While  the 
tubes  were  still  full,  the  bottle  was  depressed  below  the  level  of  the  patient's  body,  and 
the  rubber  tube  was  detached  from  the  bottle.  By  the  syphon  thus  made,  the  fluid 
passed  out,  emptying  the  stomach. 

3  Wiener  Med.  Wochenschrift,  Feb.  5,  1881 ;  Med.  Times  and  Gazette,  March  5,  1881. 
Pean  had  performed  this  operation,  1829  ;  but  his  patient  died. 

^Allgemeine  Wiener  mediciuische  Zeitung,  March  15,  1881. 

4  Lancet,  March  14,  1874. 

6  Dr.  D'Arpen,  of  Elba,  has  reported  the  apparently  curative  effects,  in  cancer  of  the 
rectum,  of  enemata  of  gastric  juice.    Lancet,  March  18,  1871. 


DYSPEPSIA.  269 

the  stomach  ;  while  deficient  power  of  the  peristaltic  intestinal 
contraction  is  perhaps  Die  most  common  cause  of  constipation. 
Possibly  the  presence  of  torulm  {saccharomycefi)  may  increase  the 
formation  of  acetic  and  lactic  acid  from  farinaceous  and  saccharine 
food,  in  some  cases.  Insufficient  or  perverted  innervation  may 
originate  or  intensify  any  or  all  of  these  morbid  states  and  actions. 
Sometimes  this  is  so  oliviously  primary  and  predominant,  as  to  jus- 
tify the  use  of  the  term,  in  certain  cases,  of  "  nervous  dyspepsia. " 

Causation. — Most  briefly,  we  may  assert  the  cause  of  dyspepsia 
to  be,  either  one  or  several  of  the  following  :  too  much  food,  or  too 
little  food  ;  imperfect  mastication,  and  hurry  in  eating  ;  too  little 
exercise  ;  too  much  fatigue  ;  excessive  study,  or  emotional  excite- 
ment ;  inordinate  use  of  ardent  spirits,  opium,  tobacco,  coffee  ;  or 
of  medicine  out  of  place. 

Treatment. — This  involves  regimen^  as  well  as  medication  ;  the 
first  is  most  important.  The  meals  should  be  regular,  and  with 
sufficient  time  allowed  ;  and  all  the  food  should  be  simple  as  well 
as  nutritious  ;  variety  being  obtained  rather  by  having  a  change 
from  day  to  day,  than  by  a  number  of  dishes  at  each  meal.  Some 
dyspeptics  are  obliged  to  eschew  variety,  and  confine  themselves 
to  a  routine  of  beef,  mutton,  and  stale  bread.  Caution  should  be 
used  not  to  blame,  unjustly,  particular  articles  as  "disagreeing," 
when  everything  disagrees,  because  of  the  state  of  the  stomach. 
But  a  sensible  person  will  be  able  mostly  to  ascertain  what  things' 
agree  best  with  his  digestion  ;  and  others  should  not  be  taken. 

Most  persons,  even  of  feeble  digestion,  can  eat  beef,  mutton, 
chicken,  turkey,  oysters  (not  fried  nor  raw,  but  roast,  panned, 
stewed  or  steamed)  ;  with  stale  bread  ;  bran  bread  occasionally, 
as  more  laxative  ;  crackers,  boiled  rice,  tomatoes,  and  young  and 
tender  beets.  When  weak  enough  to  require  any  stimulant, 
sherry,  or  Madeira  wine,  or  ale,  or  in  the  feeblest,  whisky,  in 
small  doses,  will  agree  best  at  dinner.  Let  Dr.  N.  Chapman's 
precept  be  here  rcm'embered,  "whatever  we  grant,  let  it  he  sparing- 
ly.''^ Advise,  for  example,  Italf  a  wineglassful  of  Madeira  or 
sherry,  or  half  a  tumblerful  of  ale,  or  one  or  two  teaspoonfuls  of 
brandy  or  whisky,  at  or  after  dinner.^  For  breakfast  and  supper, 
tea  will  be  the  best  drink  for  refreshment ;  milk  for  nourishment ; 
although  some  persons  do  not  digest  milk  with  ease.  Coffee  I 
have  so  often  known  to  produce  dyspepsia,  that  I  would  forbid 
it  altogether ;  notwithstanding  its  toleration  by  some  highly 
respectable  authorities.  Cocoa  is  too  rich  for  most  dyspeptic 
stomachs  ;  some  find  it  acceptable.  Fruit,  especially  when  fresh, 
as  a  general  rule  is  useful ;  peaches,  in  season,  are  so  with  few 
exceptions.  Stewed  fruit  also  is  excellent  for  laxative  effect. 
Preserves,  cakes,  and  pies  must  be  avoided.  If  a  full  meal  can- 
not be  taken  without  discomfort,  it  will  be  better  to  appease 
hunger  or  sustain  strength  by  a  small  and  simple  "bite  "  between 
meals.  Idleness  and  emptiness,  as  well  as  repletion,  in  the 
stomach  promote  disorder.     Dr.  Brown-Sequard  has  proposed  to 

'  The  author  must  dissent  strongly  from  Dr.  Anstie's  opinion,  that  even  a  perfectly 
healthy  aflult  will  receive  benefit  from  the  use  of  at  least  an  ounce  of  alcohol,  in  some 
form  daily.  Perfect  health,  I  believe,  is  best  maintained  with  none.  The  careful  experi- 
ments of  Drs.  Parkes,  Richardson,  and  others  fully  sustain  this  opinion. 

23* 


270        DISEASES   OF   ORGANS  OF   DIGESTION. 

treat  obstinate  cases  of  dyspepsia  by  administering  very  small 
quantities  of  digestible  food,  at  very  short  intervals.  Sometimes, 
in  desperate  cases,  this  may  be  temporarily  important ;  but  it 
must  soon  become  inconvenient  and  tiresome,  if,  as  he  advises, 
the  intervals  be  made  so  short  as  fractions  of  an  hour. 

Exercise,  daily,  in  the  open  air,  is  very  important  to  the  dys- 
peptic.    So  is  bathing,  to  maintain 
Fig.  98.  healthy   action   of  the   skin,   with 

which   the   stomach   sympathizes. 
"  But  active  exercise  ought  not  to 

g      be  taken  just  before  or  just  after  a 
<&         **  meal.     "After  dinner  sit  awhile." 

0  ®  Mental  states  and  nervous  im- 

^  pressions  are  of  great  consequence. 

Q         Anxious  occupation,  or  harassing 
_       ffl  responsibility,  may  increase  greatly 

®      ^    the   difficulty   of  recovery.     Thus 
^  *  ^  ®  *      ^^        travelling,  or  resorting  to  watering- 

*  places,  with  release  from  care,  may 

Sarcinae.  assist  the  cure. 

The  medical  treatment  of  dys- 
pepsia involves  a  number  of  indications,  not  always  exactly  the 
same.  Especially  are  tonics^  laxatives,  anta/iids,  and  other  palli- 
atives and  alteratives,  apt  to  be  required. 

Tonics. — Pure  vegetable  bitters,  as  gentian  [F.  72,  73] ,  quassia, 
and  columbo,  are  most  suitable  as  direct  stomachics.  Chiretta 
is  a  favorite  with  some.  Oxide  of  silver  has  had  one  or  two 
enthusiastic  advocates.  Where  nervous  debility  is  prominent,  and 
particularly  in  cases  of  long  standing,  extract  of  nux  vomica  [F. 
71],  or  strychnia  in  very  small  doses  (one-fortieth  to  one-thirtieth 
of  a  grain)  will  often  do  more  good  than  any  other  medicine. 
Iodide  of  iron,  in  aneemic  cases,  may  be  given. 

Laxatives. — Khubarb  has  been,  time  out  of  mind,  the  standby 
for  habitual  constipation  [F.  75,  76,  77] .  If  it  be  insufficient  alone, 
or  lose  its  effect,  compound  extract  of  colocynth,  aloes,  or  resina 
podophylli  may  be  added,  in  pill.  Senna,  magnesia,  and  sulphur 
may  be  used  occasionally,  for  special  indications.  Saratoga,  Chel- 
tenham, Yichy,  and  Hunyadi  Janos  (half  a  wineglassful  or  more 
at  a  dose)  waters  are  found  sometimes  to  have  excellent  regulat- 
ing effects. 

Antacids. — After  meals,  a  pinch  of  bicarbonate  of  sodium  (gr.  v 
to  gr.  x)  or  half  as  much  bicarbonate  of  potassium,  or  a  dessert- 
spoonful of  lime-water,  will,  in  cases  of  acidity,  contribute  much 
to  the  comfort  of  the  patient.  Carbonate  of^  magnesium  and 
aromatic  spirit  of  ammonia  are  preferred  by  some  ;  and  charcoal 
has  useful  absorbent  powers.  Sulphite  and  hyposulphite  of  cal- 
cium or  sodium,  for  antiseptic  effect,  may  also  be  given  to  allay 
the  after  symptoms  of  indigestion. 

Alteratives. — In  the  commencement  of  the  treatment  of  a  case 
of  dyspepsia,  in  which  derangement,  and  commonly  inaction,  of 
the  liver  is  most  generally  present,  experience  fully  justifies  the 
moderate  use  of  blue  pill.  I  prefer  to  give  it  in  fractional  doses, 
in  such  a  case,  say  gr.  i  thrice  daily  for  a  week  [F.  74] .     Occa- 


DYSPEPSIA.  271 

sionally  it  may  require  to  be -repeated,  at  intervals;  but  should 
never  be  pushed  to  salivation.  Nitro-muriatie  acid,  in  3  or  4 
drop  doses,  acts  as  a  mild  tonic  both  to  the  stomach  and  the 
liver;  and  may  well  follow  blue  mass,  when  hepatic  torpor  is 
believed  to  exist.  The  same  indication  may  be  met,  with  less 
certainty,  by  taraxacum.  Nitric  acid  is  lauded  by  some  practi- 
tioners. Leube  urges  hydrochloric  acid  instead.  Chloride  of 
ammonium  acts  very  well  with  some  ''bilious"  patients.  Among 
the  agents  shown  by  Corvisart,  Blondlot,  Lehmann,  and  Bernard 
to  increase  the  secretion  of  gastric  juice,  were  alkalies,  common 
salt,  diluted  alcohol,  ether,  ipecacuanha,  and  nitrate  of  bismuth. 
Fepsin^^  when  pure  and  fresh,  may  be  of  considerable  service; 
and  so  may  lactopeptine,  and  Savory's  essence  of  pepsin  and 
pancreatin.  Bouchut  praises  an  extractive  of  the  pojxtya  plant, 
of  Java  and  S,  America,  as  a  sort  of  vegetable  pe])sm.  Ingluvin, 
from  the  gizzard  of  the  fowl,  is  said  by  some  practitioners  to 
have  simitar  effects  to  those  of  pepsin.  English  practitioners 
make  considerable  use  in  dyspepsia  of  "liquor  pancreaticus" 
(containing  the  pancreatic  ferment  trypsin),  along  with  a  small 
quantity  of  bicarbonate  of  sodium  to  prevent  its  action  from 
being  arrested  by  the  gastric  acid  in  the  stomach  (W.  Eoberts). 

Cardialgia  seems  to  depend  mainly  upon  acidity,  aggravated 
perhaps  by  butyric  fermentation.  Aromatic  spirit  of  ammonia, 
tincture  of  ginger,  and  camphor-water,  as  well  as  the  antacids 
above  named,  may  be  given  tor  it ;  or  chloroform,  in  5  or  10  drop 
doses  [F.  78]. 

Gastrodynia  is  a  technical  name  for  stomach-ache,  common  in 
dyspeptics.  Carminatives  are  appropriate  for  it ;  one  of  the  best 
of  these  is  oil  of  cajuput,  5  drops  at  a  dose,  on  a  lump  of  sugar. 
Spirits  of  camphor,  compound  spirits  of  lavender,  compound 
tincture  of  cardamom,  and  essence  of  ginger,  are  among  the 
most  popular  preparations  for  its  relief.  A  mouthful  of  very  hot 
water  will  sometimes  quell  the  pain. 

Pyrosis  (water-brash)  is  best  treated  by  mild  astringents ;  as 
oil  of  amber,  catechu,  krameria,  ammonio-ferric  alum  [F.  80], 
creasote  {j-  drop  or  J  drop  doses)  [F.  81],  tincture  of  chloride  of 
iron.  Dr.  Lawson  considers  the  sulphites  to  be  almost  infallible 
in  the  treatment  of  pyrosis. 

For  hiccough,  which  is  an  occasional  symptom  of  either  acute 
or  chronic  indigestion,  hydrate  of  chloral  has  been  found'  to  be  a 
useful  remedy. 

After  all,  the  dyspeptic  may  be  able  to  do  the  most  for  his  own 
cure.     In  the  words  of  the  late  Prof.  N.  Chapman,  "If  he  be 

1  Dr.  Chambers,  of  London,  speaks  well  of  "  Boudault's  pepsin,"  obtained  from  the 
sheep's  stomach.  Dr.  Pavy,  of  London,  states  that  a  large  part  of  Boudault's  pepsin  is 
inert.  Glycerin  extract  of  pepsin  is  said  by  some  good  authorities  (Natur^  18/0)  to  be 
active  and  stable.  Br.  L.  Beale  asserts  that  pepsin  can  be  obtained  in  an  effective  state 
by  quickly  drvin<r  the  mucus  expressed  from  the  pig's  stomach-glands  upon  glass  pla.es ; 
the  dried  mucus  being  then  powdered  and  kept  in  stoppered  bottles.  (^Sied.  Press  and 
Circular,  MaEfh  1,  1871.)  The  late  Prof.  William  Procter,  of  Philadelphia,  perfected  a 
process  for  obtaining  a  reliable  preparation  of  pepsin,  which  can  now  be  obtained  ot 
the  leading  American  druggists.  Dr.  R,  T.  Edes  (Boston  Med.  and  Surg.  Journal,  Jan. 
1,  1874),  after  examination,  speaks  very  favorably  of  pepsin  prepared  by  Schaffer  s  pro- 

="T.eavitt,  Am.  Journ.  of  Med.  Sciences,  April,  1871 ;  and  Whithead,  N.  Y.  Med.  Record, 
April  1,  1871, 


272        DISEASES   OF   ORGANS  OP   DIGESTION. 


intemperate,  he  is  to  becorae  sober ;  if  he  use  opium  or  tobacco, 
he  must  relinquish  it ;  if  indolent,  he  must  be  awakened  to 
enterprise ;  if  luxurious,  he  must  consent  to  change  his  scheme 
of  life ;  if  studious,  to  abandon  the  midnight  lamp ;  if  afflicted, 
we  must  cheer  him  with  the  light  of  hope;  or,  if  this  be  diffi- 
cult, give  him  the  great  consolation  of  occupation,  interest,  em- 
ployment." 
The  following  table  is,  with  some  modification,  from  Leared : — 


EAST  OF  DIGESTION. 

Beef, 

Venison, 

Hare, 

Sweetbread, 

Chicken, 

Turkey, 

Partridge, 

Pheasant, 

Grouse, 

Beef-tea, 

Mutton  broth, 

Milk, 

Turbot, 

Shad, 

Flounder, 

Sole, 

Fresh  fish  generally, 

Roasted  oysters. 

Stale  bread, 

Rice, 

Tapioca, 

Sago, 

Arrowroot, 

Asparagus, 

French  beans. 

Cauliflower, 

Baked  apples, 

Oranges, 

Grapes, 

Currants, 

Peaches, 

Toast  water. 

Black  tea. 

Sherry, 

Claret, 

Ale. 


MODERATELY  DIGESTIBLE.        HARD  TO  DIGEST. 


Mutton, 

Lamb, 

Rabbit, 

Young  pigeon, 

Duck, 

Wild  waterfowl, 

Woodcock, 

Snipe, 

Soups, 

Eggs, 

Butter, 

Turtle, 

Cod, 

Pike, 

Trout, 

Raw  or  stewed  oysters, 

Potatoes, 

Beets, 

Turnips, 

Cabbage, 

Spinach, 

Artichoke, 

Lettuce, 

Celery, 

Apples, 

Apricots, 

Strawberries, 

Raspberries, 

Fresh  bread, 

Farinaceous  puddings, 

Jelly, 

Rhubarb  plant, 

Cooked  fruits. 

Cocoa, 

CoiFee, 

Porter. 


Pork, 

Veal, 

Goose, 

Liver, 

Heart, 

Brain, 

Salt  meat. 

Sausage, 

Mackerel, 

Eels, 

Salmon, 

Herring, 

Halibut, 

Salt  fish. 

Lobster, 

Crabs, 

Shrimps, 

Mussels, 

Oil, 

Melted  butter. 

Raw  eggs. 

Cheese, 

Fresh  bread. 

Muffins, 

Buttered  toast, 

Pastiy. 

Cakes, 

Custards, 

Nuts,  pears,  plums. 

Cherries,  pineapples. 

Cucumbers,  onions, 

Carrots,  parsnips, 

Peas,  beans, 

Mushrooms, 

Pickles, 

Champagne. 


CONSTIPATION  OF  THE  BOWELS. 

There  is  no  more  frequent  source  of  bodily  discomfort  than  this ; 
and  it  may  produce  or  increase  a  tendency  to  serious  disease. 
The  principal  causes  of  constipation  are— neglect  of  timely  attend- 
ance upon  the  call  of  nature  ;  want  of  exercise;  excess  of  mental 
strain  ;  and  all  the  causes  of  dyspepsia,  of  which  it  is  an  almost 
constant  part.  Organic  obstructions  may  also,  of  course,  give 
rise  to  it ;  as  stricture,  cancer,  or  other  disease  of  the  large  in- 
testines, or  a  tumor  so  situated  as  to  press  upon  the  rectum  ;  or 
pregnancy.     The  most  remarkable  instances  of  constipation  I 


ENTERITIS.  273 

have  met  with,  in  the  absence  of  mechanical  obstruction,  have 
been  in  sea-sickness.' 

Effects  of  inaction  or  non-evacuation  of  the  bowels  may  be, 
enteric  irritation,  or  even  intlammation  ;  when  much  prolonged, 
dangerous  intestinal  obstruction  ;  in  other  histances,  diarrhoea ; 
sympathetic  headache,  stomach,  or  liver  disorder  ;  urino-genital 
irritation  ;  ofiensive  perspiration  ;  and  contamination  of  the  Ijlood, 
by  the  retention  of  excretory  matter  which  the  bowels  ought  to 
remove. 

Pathologically,  costiveness  may  depend  either  upon  muscular 
torpor  of  the  intestinal  canal,  or  defective  glandular  secretion, 
or  both. 

The  treatment  of  constipation  involves  management  as  well  as 
medicine.  It  is  well  to  have  a  regular  time  to  endeavor  to  empty 
the  rectum.  Straining  is  not  beneficial,  as  it  endangers  piles  or 
prolapsus  ani  ;  but  the  act  of  defecation  may  be  facilitated  by 
kneading  the  lower  half  of  the  abdomen  with  the  hands,  so  as  to 
increase  and  aid  peristaltic  contraction. 

In  diet,  fresh  and  stewed  fruits  are  the  best  natural  laxatives. 
Prunes  are  especially  opening.  Bran  bread,  by  the  mechanical 
quality  of  the  particles,  is  somewhat  of  a  peristaltic  persuader. 
Molasses  occasionally  will  do,  but  it  is  too  acescent  to  be  taken 
constantly. 

Of  medicines,  simple  rhubarb,  or  pills  of  rhubarb  and  castile 
soap,  one  and  a  half  grains  each,  may  come  first ;  afterwards 
podophylliu  [F.  82],  colocynth,  aloes,  etc.,  if  needed  for  especial 
torpor.  An  occasional  dose  of  senna  infusion  may  give  a  good 
start  to  the  bowels.  Better  than  to  take  medicine  every  day  or 
two,  will  be  the  use  sometimes  of  enemuta.  An  injection  of  warm 
water  alone  may  answer  at  first.  Then  white  soap,  and  after- 
wards brown  soap  may  be  added ;  salt  and  molasses,  sweet  oil  or 
castor  oil  when  the  former  fail.  A  suppository  of  soap  [F.  83]  is 
less  disagreeable  to  some  j-.ersons,  and  will  generally  act  well. 

"Where  the  torpor  of  the  rectum  apjiroaches  a  paralytic  state  of 
the  muscular  coat,  nux  vomica  will  be  very  important  [F.  84,  85]. 
The  addition  of  belladonna  to  laxative  pills  for  chronic  constipa- 
tion is  a  not  uncommon  practice.  Electricity  may  assist  in  reliev- 
ing the  same  condition. 

ENTERITIS. 

Definition. — Inflammation  of  the  bowels. 

Symptoms. — Pain  in  a  portion  of  the  abdomen,  increased  by 
motion  or  pressure ;  constipation ;  fever.  Later,  abdominal 
sweUing,  vomiting,  and  mucous,  sanguinolent,  or  even  purulent 
diarrhoea  in  bad  cases. 

Causes. — Blows  or  other  injuries  ;  neglected  constipation,  expo- 
sure to  cold  and  wet.  Corrosive  poisons,  as  arsenic,  etc.,  also  cause 
enteric  inflammation  ;  and  it  is  a  part  of  the  results  of  strangulated 
hernia  or  other  intestinal  obstruction. 


1  I  have,  wheu  at  sea,  passed  seven  days  without  any  inclination  for  a  movement: 
and  a  geutleiuau  told  aie  that  he  had  been  eleven  days  without  an  evacuation  during 
a  voyage. 

s 


274        DISEASES   OF   ORGANS   OF   DIGESTION. 

Treatment.— A  decidedly  open  and  ac(u-e  case  may  require  early 
venesection  in  the  robust.  Leeching  should  be  the  rule  ;  and  it 
may  generally  be  free.  After  that,  poultices,  of  flaxseed  meal  or 
Indian  mush,  covered  with  oiled  silk  to  retain  moisture.  Soft  food 
alone  can  be  taken,  as  arrowroot,  oat-meal  gruel,  etc. ,  or,  for  weak 
persons,  beef-tea.  No  medicine  will  do  any  good,  unless  it  be 
opium  in  moderate  doses,  to  relieve  severe  pain  and  promote  rest. 
Cathartics  are  to  be  avoided,  and  entire  stillness  of  the  body  in 
bed  must  be  maintained.  From  slight  or  moderate  inflammation 
of  the  bowels  recovery  may  be  confidently  expected,  with  care  ; 
but  aggravated  cases  of  it  are  frequently  fatal. 

Typhlitis  is  inflammation  of  the  caecum  or  caput  coli.  It  is 
rather  more  common  than  other  forms  of  enteritis,  especially  after 
neglected  constipation.  Peri-typhlitis  is  a  more  obscure  afi"ec- 
tion,  involving  a  local  or  circumscribed  peritoneal  inflamma- 
tion with  typhlitis.  Wirth^  has  given  reason  for  believing  that 
inflammation  and  ulceration  of  the  vermiform  appendix  has  to 
do  with  many  of  these  cases.  Pain,  tenderness,  swelling,  and 
dull  resonance  on  percussion,  in  the  right  iliac  fossa,  with  con- 
stipation, are  the  symptoms.  A  number  of  cases  which  I  have 
seen  have  all  recovered.  "With  more  especial  propriety  than 
in  most  other  cases  of  enteritis,  opening  the  bowels,  by  enemata 
at  least,  and  even  by  a  mild  laxative,  as  castor  oil,  is  indicated. 
Rest,  leeching,  poulticing,  and  soft  diet  are  the  other  main  parts 
of  the  treatment. 

Abscess  may  occur  ;  with  safe  issue  if  it  open  outwardly,  fatal 
if  it  rupture  into  the  peritoneal  cavity.  Dr.  Bull  {N.  Y.  Med. 
Journ.,  Sept.,  1873)  advises  early  use  of  the  aspirator  in  such 
cases. 

-  Dr.  Flint^  remarks  upon  the  "  uniform  success  "  of  the  opera- 
tion for  peri-typhlitic  abscess,  by  opening  it  as  soon  as  the  nature 
of  the  case  is  determined,  without  even  waiting  for  fluctuation. 
He  refers  to  the  performance  of  this  operation  by  Hancock  in 
1848 ;  Willard  Parker,  1867 ;  and  since  that  time,  by  G.  Buck,  H. 
B.  Sands,  J.  E.  Wood,  E.  Weber,  and  others. 

Dr.  Sands  has  recorded^  the  history  of  twenty  cases  of  peri- 
typhlitis, of  which  resolution  took  place  in  seven ;  recovery  after 
operation  in  eight ;  recovery  after  abscess  into  bladder,  one  ;  recov- 
ery after  rupture  into  rectum,  one  ;  death  after  abscess  had  been 
opened,  one;  death  after  unsuccessful  attempt  to  reach  the  abscess, 
one ;  death  without  operation  (from  secondary  meningitis),  one. 
Dr.  Sands  prefers  W.  Parker's  operation.  An  incision  two  inches 
long  is  made,  parallel  to  Poupart's  ligament,  over  the  centre  of 
the  tumescent  region.  After  cautiously  dividing  the  abdominal 
wall  to  the  level  of  the  fascia  transversalis,  the  hypodermic  syr- 
inge is  used  for  exploration  to  determine  the  exact  locality  of  the 
abscess.  Then  a  deep  incision  is  made,  half  an  inch  in  length. 
The  wound  should  be  kept  open  (by  a  tent  or  drainage  tube)  to 
discharge  for  several  days. 


1  London  Med.  Record,  June  15, 1880. 

2  Clinical  Medicine,  p.  311. 

3  N.  Y.  Med.  Kecord,  Jan.  19, 1878. 


PERITONITIS,  275 

PERITONITIS. 

Inflammation  of  the  peritoneum  is  one  of  tlie  most  dangerous 
of  the  phlegmasia^  liecause  of  the  extent  and  important  connec- 
tions of  tlie  membrane  involved. 

Varieties. — Simple  or  idiopathic ;  accidental  or  traumatic ; 
tul)ereular ;  puerperal. 

Causes.— Exposure  to  cold  and  wet;  falls,  blows,  wounds,  or 
other  injuries  ;  abscess  of  the  liver  ;  opening  of  aneurism,  or  per- 
foration of  gastric  or  intestinal  ulcer  (as  in  typhoid  fever);  tuber- 
culization ;  accidents  of  the  puerperal  state. 

Symptoms. — Diffused  abdominal  pain  and  tenderness,  increased 
greatly  even  by  diyJit  movements,  as  breathing  deeply  or  raising 
the  lower  limbs  in  bed  ;  vomiting  ;  constipation  ;  tympanites ; 
fever ;  with  very  rapid,  though  not  full  pulse.  Later,  that  is,  in 
three  or  four  days,  in  violent  cases,  delirium,  insomnia,  collapse. 
Its  course  is  usually  rapid  ;  from  the  incipient  chill  to  the  fatal 
end,  often  occupying  less  than  a  week,  though  sometimes  two. 
Simple  sporadic  peritonitis,  however,  even  in  puerperal  women, 
is,  with  careful  treatment,  much  more  often  recovered  from  than 
not. 

Diagnosis. — The  most  important  point  is  the  discrimination  of 
"simple  peritonitis  or  metro-peritonitis  in  the  puerperal  state  " 
from  puerperal  fever.  The  main  difficulty  about  this  is  that  the 
latter  disease  includes  peritonitis  almost  as  constantly  as  erysip- 
elas does  diftusive  inflammation  of  the  skin.  We  can  best  discuss 
this  diflerential  diagnosis  after  considering  the  fever  in  question. 
(See  Puerperal  Fever.)  Occasionally,  in  children,  the  signs  of 
peri-t}q)hlitis  may  considerably  resemble  those  of  an  early  and 
inflammatory  stage  of  coxcdejicc.  This  possibility  needs,  however, 
onljr  to  be  pointed  out  for  the  careful  practitioner  to  be  upon  his 
guard  to  avoid  mistaking  one  of  these  affections  for  the  other. 
(See  Coxalgia,  under  Diatheses,  later  in  the  book.) 

Morbid  Anatomy. — After  death  from  peritonitis,  the  swollen 
abdomen  is  found  nearly  always  to  contain  fluid,  often  consider- 
able in  amount,  serous,  sero-sanguiuolent,  sero-purulent,  or  pus. 
The  latter  may  form  in  a  very  few  days  ;  some  facts  have  made 
it  probable,  even  within  forty-eight  hours.  Adhesions  are  present, 
with  bands  and  false  membranes  of  coagulable  lymph,  in  various 
parts  of  the  abdominal  cavity  ;  and  redness,  thickening,  and 
opacity  exist  to  a  greater  extent. 

Treatment. — No  disease  requires  or  bears  better  the  early  use 
of  the  lancet  than  sporadic  (non-epidemic)  acute  peritonitis.  One 
free  bleeding  may  sometimes,  as  it  were,  arrest  the  conflagration. 
Yet,  apart  from  epidemic  puerperal  fever,  in  which  large  bleeding 
has,  upon  the  amplest  trial,  proved  rather  destructive  than  cura- 
tive, there  are  cases  in  which  the  need  of  economy  of  material 
makes  venesection  unsafe.  Then  leeching  may  be  resorted  to,  in 
all  but  the  very  feeblest  subjects.  Fifty  or  a  hundred  American 
leeches  may  be  borne  upon  ithe  abdomen  by  a  patient  who  would 
faint  if  the  same  amount  of  blood  were  taken  rapidly  from  a 
vein.  Exposure  of  the  body,  during  leeching,  may  be,  with  care, 
avoided.  Poulticing  with  flaxseed  or  Indian  meal  should  follow 
the  leeching ;  the  poultices  should  be  large,  but  light,  and  covered 


276  DISEASES   OP    ORGANS   OF    DIGESTION. 

with  oiled  silk,  or  changed  very  frequently  to  maintain  warmth. 
If  no  leeches  have  been  used,  llannel  dipped  in  spirits  of  turpen- 
tine may  be  put  all  over  the  belly.  Later,  if  the  case  threaten 
obstinacy,  a  large  blister  should  be  applied. 

Of  medicines,  opium  has  now  the  general  confidence  of  practi- 
tioners. Except  emptying  the  rectum  at  first  by  mild  enemata, 
no  agitation  of  the  bowels  by  medicine  is  to  be  encouraged. 
Calomel,  as  an  antiplastic,  has  been  long  valued  by  physicians  of 
sagacity  and  experience.  Though  unable  to  prove  that  it  does 
lessen  the  tendency  to  the  effusion  of  coagulable  lymph,  I  bow  to 
the  rational  empiricism  which,  not  hastily,  in  time  past,  raised  it 
to  the  position  of  reliance  for  that  end.  I  am  not  satisfied  that 
its  utility  as  an  antiphlogistic,  especially  in  severe  inflammations, 
has  been  disproved.^ 

With  opium,  then,  I  would,  in  peritonitis,  give  calomel :  ^  grain 
to  one  grain  of  the  former,  with  as  much  or  less  of  the  latter,  every 
two,  three,  or  four  hours,  according  to  the  severity  of  the  pain, 
and  the  urgency  of  the  case  [F.  86,  87].  When  the  stage  of  debil- 
ity comes  on — or  in  very  feeble  cases  from  the  first  —  quinine, 
instead  of  calomel,  may  be  combined  with  opium ;  and  support 
with  beef-tea,  and  wine,  brandy,  or  whisky,  may  be  required. 

The  use  of  opium  after  bleeding  in  peritonitis,  was  introduced 
by  Armstrong,  in  England,  many  years  ago.  Opium  without  bleed- 
ing, and  in  large  doses  (from  two  grains  every  two  hours  up  to 
much  greater  amounts)  is,  as  a  treatment,  credited  to  Dr.  A. 
Clark,  of  Kew  York  (1841).^  He  applied  it  with  great  success  in 
epidemic  puerperal  as  well  as  in  ordinary  sporadic  peritonitis. 
My  own  experience  has  led  me  to  recognize  a  decided  difference 
in  the  therapeutic  indication  in  simple,  sporadic  peritonitis  and 
in  puerperal  fever.  In  the  former,  I  liave  known  free  venesection 
to  be  followed  by  rapid  recovery.  In  the  latter,  I  witnessed  the 
signal  failure  of  the  same  treatment  in  hospital  epidemics,  as 
long  ago  as  1845-48. 

When  peritonitis  follows  an  injury,  the  treatment  may  neces- 
sarily have  to  be  modified  by  the  concomitant  states  of  other 
organs  involved,  or  by  the  general  shock  of  the  system.  So,  also, 
when  perforation  of  an  ulcer  of  the  stomach  or  bowel,  or  the  rup- 
ture of  an  hepatic  or  other  abscess  or  aneurism,  brings  it  on — 
collapse  is  apt  to  occur  speedily,  forbidding  any  except  anodyne 
and  supporting  treatment,  and  affording  very  little  hope  of  favor- 
able reaction.     Such  cases  are  almost  invariably  fatal. 

Chronic  peritonitis  is  sometimes  met  with.  When  not  tubercu- 
lous, although  a  very  serious  affection,  it  may  be  recovered  from  ; 
the  tubercular  form,  not  with  any  more  probability  than  pulmo- 
nary phthisis.  Like  that  disease,  however,  it  is  not  always  incur- 
able. Gee,  Wells,  Eagge  and  others  have  given  authentic  reports 
of  recovery  from  it,  especially  in  children. 

Chronic  peritonitis  should  be  treated  by  rest  in  the  recumbent 

1  Prof.  John  Marshall,  of  University  College,  London,  has  recommended  the  local 
application,  for  persistent  inflammations,  of  the  oleate  of  mercury  with  morphia;  made 
by  adding  oxide  of  mercury  to  oleic  acid,  at  300°  F.,  and  afterwards  adding  morphia. 
It  may  be  applied  in  warm  or  hot  solutiou,  with  a  brush  or  very  soft  sponge. 

2  Ramsbotham's  System  of  Obstetrics,  Amer.  editipn,  1855,  p.  533 ;  also,  Amer.  Journal 
of  Med.  Sciences,  July,  1876,  p.  144 


COLIC.  277 

posture  (in  tedious  cascis  the  patient  may  l)c  carried  out  into  the 
sunshine  and  air),  with  resolvent  and  counter-irritant  local  appli- 
cations ;  as  repeated  blisters,  tincture  of  iodine,  mercurial  oint- 
ment, unguent  of  iodoform,  cerate  of  carbonate  of  lead.  The 
latter,  as  a  local  sedative,  I  have  sometimes  found  to  have  re- 
markable power.  It  may  be  prepared  by  adding  gij  of  carbonate 
of  lead  to  gj  of  fresh  simple  cerate  [F.  88j. 

COLIC. 

Varieties. — 1.  Flatulent.  2.  Bilious.  3.  Spasmodic,  gouty, 
or  rheumatic.  4.  Learl  colic.  Some  writers  speak  of  nephritic 
colic  ;  the  pain  of  which  is  chiefly  owing  to  the  passage  of  small 
calculi,  from  the  kidney  to  the  ureter ;  while  newalyia  of  the 
bowels  may  also  cause  pain  of  similar  seat  to  colic.  Uterine 
colic,  in  females,  may  be  either  neuralgic,  spasmodic,  or  obstruc- 
tive (dysmenorrhcea).  Attacks  of  ovarian  pain  are,  with  some 
women,  periodic.  The  following  passage  (from  Cornillon^)  is 
instructive : 

"  There  is  not  the  least  resemblance  between  the  painful 
points  in  hepatic  colic  and  those  of  nephritic  colic.  In  the  first 
place,  the  latter  are  incomparably  the  most  severe.  In  addition, 
the  first  are  seated  at  the  base  of  the  thorax  and  above  that 
point,  as  in  the  epigastric,  cystic,  dorsal,  and  scapular  regions, 
while  the  pains  in  nephritic  colic  are  referred  to  the  inferior 
segment  of  the  body, — the  renal,  lum])ar,  inguinal,  and  testicu- 
lar regions.  In  doubtful  cases  the  exact  determination  of  their 
respective  position  is  an  excellent  point  in  the  diflerential  diag- 
nosis." 

Flatulent  Colic. — This  is  caused  by  indigestion ;  as,  from  excess 
in  the  amount,  or  error  in  the  quality  of  food  ;  or,  from  cold  and 
wet,  arresting  perspiration  and  disturbing  the  balance  of  the 
"aqueous  visceral  circulation,"  which  is  indispensable  to  nor- 
mal digestion.  Acrid  irritation  and  gaseous  distention  produce 
irregular  tonic  or  spasmodic  contractions  in  the  intestines  ;  prin- 
cipally in  the  colon.  They  are  not  confined  to  this,  however. 
In  a  woman  with  irreducible  umbilical  hernia,  I  have,  during  an 
attack  of  colic,  felt  a  portion  of  small  intestine,  several  inches 
in  length,  grow  rigid  during  the  access  of  pain,  and  relax  when 
it  was  relieved.  Sometimes  the  stomach  itself  is  the  seat  of 
pain. 

In  flatulent  or  crapulent  colic  the  abdomen  is  distended,  but 
not  very  tender,  except  after  long  continuance  of  the  attack. 
There  is  constipation  of  the  bowels  ;  often  nausea,  with  belching 
of  wind,  sometimes  vomiting  ;  no  fever.  A  sign  of  the  yielding 
of  the  attack  is  audible  or  palpable  rumbling  of  wind  in  the 
bowels  ;  showing  a  return  of  the  arrested  peristaltic  motion. 

Bilious  Colic. — The  onset  in  this  form  is  slower.  Nausea  is 
greater,,  and  vomiting,  of  a  greenish  or  yellowish  (biliary)  fluid, 
is  nearly  constant.  The  pain  may  last,  with  very  slight  remis- 
sion, for  a  number  of  days.    The  bowels  are  constipated.    There 

1  Le  Progpfis  Medical,  1880,  p.  601. 

24 


278        DISEASES   OF   ORGANS   OF   DIGESTION". 

may  be  considerable  fever,  and  some  tenderness  of  tbe  abdomen 
on  pressure.  Meteorism  is  generally  present ;  but  less  in  pro- 
portion to  the  pain  than  in  flatulent  colic.  In  protracted  cases, 
slight  or  moderate  jaundice  is  quite  common. 

The  greatest  suffering  in  cases  of  bilious  colic  is  attendant 
upon  the  passage  of  gall-stones  from  the  gall-bladder  to  the 
duodenum.  Then,  the  pain  is  chiefly  in  the  right  hypochondriac 
and  lower  part  of  the  epigastric  region ;  and  sudden  relief  fol- 
lows the  escape  of  the  calculus  from  the  ductus  choledochus  into 
the  intestinal  canal.  In  other  cases,  we  suppose  the  irritant 
giving  rise  to  spasmodic  pain  to  be  acrid,  unhealthy  bile ; 
which  escapes  into  the  intestines,  and  also,  through  the  pylorus, 
into  the  stomach.  Of  course  it  is  quite  possible  for  the  same 
condition  of  the  stomach  or  intestinal  canal  which  attends 
flatulent  colic  to  coexist  with  hepatic  derangement,  without 
bile  being  a  direct  cause  of  local  irritation.  Anger,  of  Menil- 
montant,  has  reported  ^  a  case  in  which,  after  attacks  of  colic 
repeated  at  intervals  for  thirty  years,  a  spontaneous  rupture 
occurred  in  a  swelling  in  the  hei^atic  region,  through  which 
were  extracted  about  a  hundred  gall-stones.  This  was  followed 
by  recovery.  (For  remarks  on  Ckolecystotomy,  see  Dilatation  of 
the  Gall-bladder.) 

Dr.  I^tnam-Jacobi  found,  in  one  case,  post-mortem  evidence 
that  spasm  of  the  gall-bladder,  from  irritation  produced  by  cal- 
culi contained  in  it  (and  not  passing  into  the  duct)  was  the  cause 
of  pain  in  repeated  attacks  of  colic. 

Fatal  impaction  of  the  bowels  (mostly  the  ileum  just  above 
the  ileo-colic  valve)  by  very  large  gall-stones  has  been  reported 
by  Stewart,  Habershon,  Abercrombie,  Murchison,  Woodbury,^ and 
others.  Such  obstruction,  however,  is  not  nearly  always  fatal. 
Sometimes  the  stone  may  at  last  escape  from  the  rectum  ;  or  it 
may  be  justifiably  removed  by  abdominal  section  (laparotomy ; 
see  Obstruction  of  the  Bowels).  Dr.  E.  Brown,  of  New  Jersey, 
recorded  a  case  in  which,  after  symptoms  of  obstruction  for 
thirteen  days,  some  purgative  pills  were  followed  by  the  expul- 
sion of  a  calculus  weighing  328  grains.^ 

Certain  persons  are  particularly  liable  to  such  attacks  •,  a  large 
majority  of  people,  indeed,  are  never  subject  to  them.  I  have 
known,  in  a  number  of  instances,  the  same  patient  to  have 
severe  bilious  colic  once  in  every  two  or  three  weeks  ;  in  others, 
the  interval  may  be  of  months  or  years.  In  one  case,  under  my 
care,  the  attack  was  fatal.  Autopsy  then  showed  rupture  of  the 
gall-duct,  under  distention  from  obstruction  by  an  impacted  cal- 
culus. This  must  be  very  unusual.  But  prolonged  bilious  colic 
is  never  quite  free  from  danger  of  inflammation  of  the.  bowels, 
or,  in  feeble  persons,  exhaustion  from  continued  suffering  and 
inanition. 

Gouty  Spasmodic  Colic. — In  the  "gouty  diathesis,"  this  is  one 
mode  in  which  the  disease  may  invade  internal  organs.  The 
stomach  is  the  most  frequent  and  dangerous  seat  of  it ;  the 

1  La  France  Medicale,  April  16,  1879.  2  Amer.  Jour.  Mecl.  Sciences,  Jan.,  1880. 

3  The  Country  Practitioner,  June,  1879,  vol.  i,  p.  19. 


COLIC.  279 

attack  boins  commonly  called  "  cramp  in  the  stomach."  It  is 
characterized  by  suddenness,  extreme  severity  of  pain,  and  ten- 
dency to  coldness  and  general  prostration  of  the  system.  Repul- 
sion of  gout  from  the  foot,  as  by  cold  applications,  may  bring 
it  on. 

Lead  Colic;  Pnintcr\s  Colic;  Colica  Pictonum. — This  disease 
has  long  been  known  as  the  result  of  exposure  to  the  poisonous 
influence  of  lead.  The  name  of  "  dry  belly-ache  "  has  also  been 
applied  to  it.  The  abdomen  is  shrwiken  and  rather  hard  ;  some- 
times knots  of  contracted  intestine  may  be  felt.  There  is  no 
tenderness,  the  pain  being  lessened  or  relieved  by  pressure.  The 
sufl'ering  is  often  extreme,  with  restlessness  ;  the  face  and  body 
being  thrown  into  grotesque  contortions.  Sometimes  delirium 
occurs.  Constipation  is  obstinate  ;  the  fseces,  when  passed,  are 
small,  drj^,  and  hard.  No  fever  exists.  There  is  (Burton)  a  blue 
line  along  the  edge  of  the  gums.  Malassez '  ascertained  that 
lead-poisoning  is  attended  by  a  diminution  in  the  number,  and 
increase  in  the  size,  of  the  red  corpuscles  of  the  blood.  Lead 
palsy  may  attend  or  follow  colic.  Amaurosis  may  supervene 
in  protracted  cases ;  ascribed,  on  ophthalmoscopic  evidence,  to 
optic  neuritis.^ 

Treatment. — In  all  forms  of  colic,  the  indications  in  common 
are,  1,  to  open  the  bowels;  2,  to  relieve  pain  and  spasm;  3,  to 
prevent  inflammation  ;  4,  to  prevent  future  attacks. 

In  flatulent  colic  we  should  ascertain  if  the  stomach  has  just 
been  overloaded,  or  any  very  unwholesome  food  has  been  taken. 
If  so,  a  prompt  emetic  will  be  proper  ;  as,  a  teaspoonful  of  mus- 
tard, or  a  tablespoonful  of  salt,  in  a  teacupful  of  warm  water — 
repeated  in  ten  minutes  if  necessary.  Then  the  antacid  laxa- 
tive, magnesia,  may  be  given  ;  a  teaspoonful,  with  ten  to  twenty 
drops  of  essence  of  ginger,  or  ten  drops  of  essence  of  pepper- 
mint, five  or  six  drops  of  oil  of  cajuput,  or  some  other  aromatic 
in  corresponding  proportion  [F.  89].  If  the  bowels  are  not 
opened,  and  relief  of  the  pain  not  obtained,  no  great  length 
of  time  must  elapse  without  an  enema  of  castor  oil,  salt  and 
molasses,  soap,  assafoetida,  or  oil  of  turpentine,  in  warm  water. 

Should  the  stomach  be  much  unsettled,  and  the  pain  violent, 
we  may  depend  upon  the  immediate  use  of  an  injection  to  open 
the  bowels  ;  and  may  give  by  the  mouth  antacids  and  carmina- 
tives. Thus  aromatic  spirit  of  ammonia,  spirits  of  camphor, 
compound  spirit  of  lavender,  essence  of  ginger,  or  oil  of  cajuput 
may  be  given,  with  bicarbonate  of  sodium  [F.  90].  Small  doses 
every  few  minutes  Avill  be  better  retained  than  larger  ones  at 
long  intervals,  and  will  act  better. 

Anodynes  come  next  in  order.  Extreme  and  sudden  cases  of 
colic,  belonging  rather  to  the  spasmodic  variety,  require  them 
at  once.  Other  cases,  the  majority,  are  best  managed  by  com- 
mencing Avith  corrective  remedies  as  above  mentioned.  When 
relief  is  not  obtained  without,  we  must  give  opium,  chloroform, 
ether,  or  Hotimann's  anodyne  [F.  91]."  The  first  is  of  all  the 

1  Le  MouTeraent  Medical,  1S73. 

2  J.  II.  Hutchinson,  Phil.  Med.  Times,  Jan.  17, 1874. 


280        DISEASES   OP   ORGANS   OF   DTGESTIOK". 

most  certain,  although  chloroform,  internally  used,  in  I  drachm 
to  I  drachm  doses,  has  not  disappointed  me.'  Paregoric  is  a 
very  good  opiate  for  this  purpose.  Pills  of  opium  (especially  old 
pills)  may  do  better  sometimes,  where  as  much  as  a  grain  at 
once  maybe  needed  for  severe  pain.  The  "chloroform  pare- 
goric "  [F.  92,  93]  combines  several  good  antispasmodics  conven- 
iently. Laudanum  is  the  oldest  stand-by,  and  well  deserves 
its  place.  Hydrate  of  chloral  is  relatively  less  valuable  in  giving 
relief  from  pain  than  in  producing  sleep. 

It  is  remarkable  how  much  opium  a  sufferer  with  great  pain 
will  sometimes  bear  without  narcotism.  I  have  known  a  tea- 
spoonful  of  laudanum  to  be  taken  at  once  ;  not  even  drowsiness 
following  it.  But  care  must  be  taken  not  to  overdo  this,  or  to 
give  any  more  than  is  really  necessary,  lest  the  remedy  prove 
worse  than  the  disease. 

An  important  part  of  the  treatment  of  colic  is  the  use  of  warm 
external  applications.     Mustard  should  come  first ;  a  large  sina- 
pism, half  and  half  with  flour  (if  the  mustard  be  of  good  strength) 
and  covered  with  gauze  or  thin  muslin,  over  the  abdomen.    When 
it  is  removed  after  making  a  decided  im- 
FiG.  99,  pression,  let  a  little  lard,  sweet  oil,  or  cold 

cream  be  rubbed  on,  to  prevent  further  irri- 
tation of  the  skin.  A  concentrated  liquid 
preparation  of  mustard  has  lately  been  in 
use.^  Then  apply  a  hot  flannel,  dry  or 
wrung  out  of  hot  whisky  and  water.  For 
the  latter  the  best  mode  is  to  add  to  very 
hot  water  an  equal  quantity  of  raw  whisky. 
Such  appliances  should  be  often  renewed,  or 
they  grow  cold.  Some  persons,  liable  to 
Gall  Stones,  colic,  keep  at  hand  a  tin  vessel  constructed 

to  hold  hot  water,  and  shaped  so  as  to  fit 
over  the  abdomen.  The  feet  of  the  patient  should  be  kept  warm  ; 
if  he  is  able  to  sit  up,  or  recline  with  the  legs  over  the  side  of 
the  bed,  a  hot  mustard  foot-bath  will  be  suitable. 

Kneading  the  abdomen  gently  with  the  hand  will  aid  to  dispel 
flatus  ;  but  it  requires  tact  not  to  make  too  violent  an  operation. 
I  have  found  considerable  relief  to  be  given  by  firm  pressure 
upon,  and  immediately  below,  both  anterior  superior  spinous 
processes  of  the  ilia,^  In  every  case  of  severe  colic  the  possi- 
bility of  hernia  must  be  held  in  mind,  and  its  presence  or  absence 
should  be  ascertained. 

Infants  are  especially  liable  to  crapulent  colic ;  some  during 
their  first  year  having  almost  daily  or  nightly  attacks.  Yery  sim- 
ple treatment  will  often  suffice  for  these  ;  in  children,  too,  over- 

1  A  good  way  of  preparing  chloroform  for  internal  use,  is  to  dissolve  it  carefully  in 
glycerin,  one  part  to  three  of  the  latter.  If,  after  standing  24  hours,  any  of  the  chloro- 
form settles,  it  should  be  separated,  and  dissolved  in  an  additional  portion  of  glycerin. 
This  preparation  may  be  dissolved  without  precipitation  in  any  quantity  of  water. 
However  given,  chloroform  requires  to  be  considerably  diluted  for  internal  adminis- 
tration. 

2  Druggists  now  keep  ready-made  sinapisms,  which  require,  for  use,  merely  to  be  im- 
mersed a  few  moments  in  warm  water. 

3  I  believe  this  observation  to  have  been  first  made  by  myself.  In  my  own  person, 
quite  severe  paiu  has  several  times  been  thus  entirely  controlled. 


COLIC. 


281 


medication  should  be  even  more  sedulously  avoided  than  in  adults. 
For  infantile  colic  of  sli.ij;ht  severity,  peppermint  water,  or  infusion 
of  fennel  seed,  will  frciquently  be  enoufrh,  with  the  application 
of  a  iv(ir7n  flannel  over  the  stomach.  Wetting  it  with  essence  of 
ginger  will  "make  it  more  efficient.     Worse  cases  may  be  treated 

Fig.  100. 


Fig.  101. 


Calculi  in  the  Gall-Bladder. 

with  lac  assafoetidte  [F.  98],  which  children  generally  take  well,  if 
it  be  sweetened,  in  teaspoonful,  or  for  very  young  infants  half  tea- 
spoonful,  doses.  Antacids,  as  bicarbonate  of  sodium,  will  assist  in 
giving  relief  [F.  9-i].  Keeping  the  bowels  reg- 
ular, never  allowing  a  day  to  pass  without  an 
evacuation,  is  most  Important  in  young 
children.  For  this  purpose  the  simple  syrup 
of  rhubarb,  manna,  and  fluid  extract  of  sen- 
na are  the  best  medicines.  The  latter  may 
give  pain,  but  is  less  apt  to  do  so  if  one  drop 
of  oil  of  cloves  be  added  to  each  fluidounce. 
A  very  small  quantity  of  resina  podophylli 
added  to  syrup  of  rhubarb  [F.  95]  will  make 
it  more  potent  when  the  bowels  are  torpid. 
Glycerin  may  be  occasionally  substituted,  in 
teaspoonful  doses. 

If  the  food  of  an  infant  becomes  acescent, 
lime-water  may  be  added  to  it  when  it  is 
taken,  e.  g.,  a  tablespoonful  of  lime-water  in 
each  pint  of  milk.     Overfeeding  an  infant  is  a  very  common  cause 
of  colic. 

Bilious  colic  may  be  attended  by  so  inflammatory  a  condition 
as.  in  a  person  of  full  vigor,  to  demand  early  and  moderate  vene- 
section. Opening  the  bowels  is  a  cardinal  indication  in  this  as 
in  the  flatulent  form.  If  the  stomach  will  bear  it,  castor  oil  will 
be  the  most  effectual  cathartic.  The  least  unpleasant  way  of 
taking  this  is  in  thorough  admixture  with  spiced  syrup  of  rhu- 
barb ;  two  tablespoonfuls  of  the  latter  with  one  of  oil.  Magnesia 
may  be  retained  better  than  oil  upon  the  stomach.  Notwith- 
standing its  effervescence,  I  have  known  the  citrate  of  magnesium 
solution  to  do  very  well  in  colic.  The  same  antacid,  carminative, 
and  anodyne  remedies  (soda,  ginger,  camphor,  etc.),  mentioned  for 
crapulent  colic,  will  be  suitable  in  the  bilious,  and  may  require 
more  persevering  administration.  So  also  euemata,  mustard 
plasters,  pediluvia,  and  warm  applications  to  the  abdomen  are  of 
24* 


Cholesterin  Tablets  and 
Glomeruli ;  from  a 
Gall-Bladder. 


282         DISEASES   OF  ORGANS  OF  DIGESTION. 

great  service.  Besides  these,  however,  a  special  indication  exists 
for  promoting  healthy  hepatic  secretions,^  so  that  it  may  be  made 
less  irritating  and  obstructive.  A  reasonable  treatment  then  is, 
besides  such  palliatives  as  have  been  named,  to  give  calomel,  with 
opium,  e.  g.,  ^  to  1  grain  of  calomel  with  about  as  much  opium, 
every  two,  three,  or  four  hours  [F.  86].  Chloride  of  ammonium 
and  resina  podophylli  are  serviceable  in  some  cases,  but,  unless 
the  podophyllum,  scarcely  prompt  enough  in  action  during  a 
severe  attack.  Leeches,  cups,  or,  later,  a  blister  over  the  liver, 
may  be  right,  if  hepatic  or  cystic  inflammation  threaten. 

When  there  is  strong  reason  to  apprehend  that  the  passage  of 
a  gall-stone  is  the  cause  of  the  severe  pain,  the  warm  bath,  if 
practicable,  will  be  useful  by  promoting  relaxation,  and  full  doses 
of  opium  may  be  called  for  by  the  patient's  agony.  Some  prefer 
to  inhale  ether  or  nitrous  oxide.  Chloroform,  taken  internally, 
has  been  used  with  advantage  by  Dr.  Buckler,^  of  Baltimore.  He 
considers  that  it  aids  in  dissolving  biliary  concretions,  as  well  as 
by  its  anodyne  power  giving  relief.  Choleate  of  sodium  has  been 
advised  for  the  former  effect,  by  M.  Schiff.^  Its  dose  is  about 
six  or  eight  grains,  twice  daily.  Dr.  E.  Kennedy,  of  Canada,  as- 
serts* that  large  doses  (six  ounces  at  once)  of  olive  oil  greatly  pro- 
mote the  easy  discharge  of  biliary  calculi  into  and  from  the  bowels. 
(On  cholecystotomy,  see  Gall  Bladder.) 

Dr.  Bartholow^  considers  pJiosphate  of  sodium  the  best  solvent 
of  biliary  calculi.    He  gives  it  in  drachm  doses,  three  times  daily. 

Gouty,  or  other,  cramp  of  the  stomach  generally  needs  very 
prompt  treatment,  essentially  stimulent  and  antispasmodic  or 
anodyne.  In  moderate  cases,  Warner's  cordial  (tinct.  rhei  et 
sennse)  has  the  advantage  of  being  laxative  as  well  as  stimulat- 
ing ;  from  a  teaspoonful  to  a  tablespoonful  may  be  given  at  once 
in  hot  water.  Essence  of  ginger,  10  drops,  or  oil  of  cajuput,  5 
or  6  drops  on  a  lump  of  sugar,  often  gives  immediate  relief.  In 
worse  attacks,  brandy,  ether,  laudanum,  and  Hoffmann's  ano- 
dyne are  more  reliable  [F.  97]  ;  with  a  sinapism  over  the  epigas- 
trium, and  a  hot  mustard  foot-bath.  Subsequent  treatment, 
prophylactic  of  future  attacks,  as  with  colchicum,  alkahes,  or 
other  medication,  must  be  pointed  out  by  the  nature  of  each  case. 

Lead  colic,  when  rapidly  produced,  maybe  treated  antidotally, 
with  sulphate  of  magnesium.  If  slowly  brought  on,  we  can  do 
much  less  in  that  way ;  although  it  has  been  asserted  that  some 
chemical  agents  possess  an  eliminative  power.  Alum  is  confided 
in  by  some,  notwithstanding  its  astringency.  Castor  oil  as  a  pur- 
gative, the  warm  bath  to  relax  spasm,  and  opium  to  relieve  spasm 
and  pain,  are  the  most  important  usual  remedies  in  this  affection. 
The  costiveness  being  mainly  spasmodic,  it  is  not  unfrequently 
found  that,  contrary  to  its  common  effect,  opium  promotes,  in 
lead  colic,  the  movement  of  the  bowels.     Iodide  of  potassium  is 

1  Eemarks  are  made  elsewhere  in  this  book  upon  the  necessity  of  maintaining  the 
validity  of  clinical  experience  with  mercurials  in  affections  of  the  liver,  notwithstanding 
the  results  of  some  experiments  upon  animals  bearing  upon  the  subject. 

2  Boston  Medical  and  Surgical  Journal,  Oct.  23,  1879,  p.  583. 

3  L'Imparziale,  No.  4, 1873.  *  Lancet,  September,  1880. 
5  Treatise'on  the  Practice  of  Medicine,  1880. 


COLIC.  283 

believed  to  exert  a  decided  power  in  removing  from  the  system 
lead  which  has  been  slowly  'deposited  in  various  organs.  In 
Germany,  farddaic  eJecti-iciti/  has  been  found  beneficial  in  lead 
colic;  also  (Weinberg)  pilocarpin.  A  milk  diet  is  recommended 
in  this  affection. 

Prevention  of  Crapulent  and  Bilious  Colic— This  becomes  the 
duty,  if  not  the  interest  of  the  physician  ;  when  his  patient  has 
been  relieved,  to  aid  him  in  escaping  returns  of  the  disorder. 
To  prevent  the  flatulent  form,  care  in  diet  and  regimen  will 
ordinarily  sufhce.  For  the  more  serious  attacks  of  bilious  colic, 
to  which  certain  persons  are  subject,  prevention  is  attainable  by 
the  same  means,  along  with  especial  attention  to  the  abdominal 
movements  and  secretions;  i.  c,  the  state  of  the  liver  and  bowels. 
I  am  sure  that  I  have  enabled  several  persons,  who  for  years  had 
been  liable  to  frequent  attacks,  to  escape  them  altogether,  by  a 
very  simple  prescription,  used  upon  the  first  threatening  of  any 
of  the  symptoms.  Blue  mass  and  rhubarb  were  here  the  sanative 
agents.  A  gentleman  who  has  suffered  terribly  with  bilious  colic 
told  me  that  twenty-grain  doses  of  extract  of  taraxacum,  taken 
once  or  twice,  have  repeatedly  averted  it  with  him.  Flowers  of 
sulphur,  or  lac  sidphuris^  given  in  teaspoonful  doses  or  less,  every 
day  or  two  for  several  weeks,  have  answered  the  same  purpose 
in  another  instance,  Olive  oil,  taken  daily,  is  commended  by 
some.  But  nothing  has  so  signally  satisfied  me,  as  a  prophylactic 
against  periodical  colic,  and  also,  by  a  similar  rationale,  against 
sick  headache^  as  the  preparation  above  alluded  to,  which  is  as 
follows : — 

B  ■ — Mass.  ex.  hydrarg.  gr.  v. 

Pulv.  rad.  rhei  et 

Ext.  gentian,  aa  ^ss. 

01  caryoptiyll.  gtt.  iv.— M. 
Div.  in  pil.  No.  20. 

S. — One  or  two  occasionally,  as  directed ;  to  be  continued  if 
required,  thrice  daily  for  several  days. 


REMEDIES  IN   COLIC. 

The  following  are  put  together  simj)ly  as  memoranda: 

Peppermint,  Fennel,  Cajuput;  Assafoetida ; 

Lavender,  Ginger ;  Hot  water ; 

Aromatic  spirit  of  ammonia ;  Brandy  ; 

Bicarbonate  of  sodium  ;  Calomel ; 

Magnesia  ;  Castor  oil ;  Enemata  of  oil,  or 

Warner's  cordial ;  Olive  oil ;  Spirits  of  turpentine,  or 

Camphor,  Ether,  Chloroform ;  Laudanum  ; 

Opium,  in  pill ;  Paregoric  ;  Sinapism  ; 

Laudanum  ;  Pediluvium ;  Kneading  ; 

Hot  flannel  or  plate  ;  Warm  bath  ; 

Pressure  on  anterior  iliac  spines ;  Hypodermic  injection  of 

morphia. 

Remember,  always,  the  possibility  of  stranrjulated  hernia  as  a 
cause  of  the  symptoms  of  colic. 


284        DISEASES   OF   ORGANS  OP  DIGESTION. 

OBSTKUCTION  OF  THE  BOWELS. 

Few  maladies  present  so  striking  a  contrast  as  this,  between 
the  facility  of  pathological  explanation  after  death  and  the  ob- 
scurity of  diagnosis  and  uncertainty  of  treatment  during  life. 

Pathological  Varieties. — Dr.  Haven  has  well  classified  these  as 
follows :  I.  Intermural :  a,  cancerous  stricture  ;  6,  non-cancerous 
stricture,  viz.,  1,  contraction  of  cicatrices  from  ulceration;  2, 
contraction  of  the  wall  of  the  intestine  from  inflammation ;  c, 
intussusception ;  cZ,  the  latter  with  polypi.  II.  Extramural :  a, 
bands  of  adhesions  from  lymph ;  6,  twists  or  displacements  ;  c, 
diverticula ;  d,  tumors  or  abscesses  ;  e,  mesocolic  or  mesenteric 
hernia  ;  /,  diaphragmatic ;  g,  omental,  and  /i,  obturator  hernia. 
III.  Intramural :  impacted  feces,  calculi,^  coagula,  curdled  milk, 
etc.  Erichsen  and  others  assert  that  severe  and  even  fatal 
obstruction  may  result  simply  from  spasmodic  colic. 

Symptoms  of  Intestinal  Obstruction.— These  are,  persistent 
constipation ;  constant  vomiting,  partly  or  altogether  stercora- 
ceous  ;  coldness  of  the  skin,  prostration,  distressed  countenance 


Fig.  102. 


retumiTi^ 


■ne^ivinj  -ptn^cSxna 


Jiectum 
Icti^  open 


Intussusception  of  Intestine. 


(facies  Hippocratica),  collapse.  Local  evidences,  rather  more 
distinctive,  are,  hardness  or  swelling  in  one  part  of  the  bowels ; 
arrest  of  enemata  at  a  certain  point,  and  of  borborygmi  (gaseous 
movements)  in  the  same  way.  If  the  obstruction  be  high  up,  sup- 
pression of  the  urine  occurs,  with  early  vomiting.  If  it  be  low  down, 
great  meteoric  distention  and  stercoraceous  vomiting.  When 
blood  is  passed  from  the  bowels,  with  such  symptoms,  intussus- 
ception may  be  inferred.  Sometimes  an  intussusception,  begin- 
ning at  the  ileo-csecal  valve,  may  so  progress  as  to  bring  the 
invaginated  portion  of  intestine  down  as  far  as  the  anus ;  where 
it  has  even  been  known  to  be  extruded.  Flint^  gives  account  of 
two  cases,  in  each  of  which  several  feet  of  intestine  were,  in  all, 
discharged.  Tremain^  also  has  reported  a  case  in  which  recovery 
took  place  after  seventeen  inches  of  intestine  had  passed  away. 


1  Dumenil  reported,  in  1881,  a  case  in  which  a  very  large  biliary  calculus  produced 
intestinal  obstruction. 

2  Principles  and  Practice  of  Medicine,  5th  edition,  p.  487. 

3  Canada  Med.  and  Surg.  Journal,  vol.  vii.,  1879,  p.  450. 


OBRTRTTOTION    OF    THE     BOWELS.  285 

Doath  is  apt  to  occur,  from  unrelieved  obstruction,  in  from  five  to 
ten  days.  W.  Hutchinson  (Lancet,  1880)  gives  account  of  a  re- 
covery in  one  case  after  tliirty-nine  days  without  fecal  evacuation. 

But,  at  last,  a  pruJjahle  diagnosis  is  sometimes  all  that  the 
nature  of  the  case  will  admit.  The  differential  discernment  of 
special  forms  of  obstruction  during  life  is  often  impossible. 

AncrMlicsia  should  be  used  in  most  cases,  to  facilitate  the 
examination  of  the  abdomen.  Sometimes  a  tumor  can  be  felt  in 
intussusception;  it  may  vary  in  form  in  the  coui'se  of  the  attack. 
Impacted  feces  will  cause  a  solid  intumescence,  rather  low  down, 
with  dulness  on  percussion,  perhaps  reaching  as  high  as  the  arch 
of  the  colon.'  The  same  may  be  expected  in  the  rare  instance 
of  obstruction  by  accumulated  worms, ^  or  by  a  very  large  biliary 
calculus. 

Treatment. — The  simple,  primary  indication  in  persistent  con- 
stipation with  unrecognized  cause,  is  cathdrsis.  Castor  oil  or 
citrate  of  magnesium  may  be  justifiably  given,  aided  or  seconded 
by  enemata  of  the  same  or  similar  purgatives.  When  the  diag- 
nosis of  intestinal  obstruction  has  been  made  out,  no  more  cathar- 
tic medicines  are  to  be  advised  ;  the  reliance  then  being  chiefly 
ui)()n  nature  and  opium.  The  use  of  opium  should  be  moderate  ; 
enough  to  allay  suffering  and  maintain  quiescence  of  the  bowels 
without  excessive  narcol;ism.  Some  practitioners  have  obtained 
advantage,  in  cases  of  supposed  partial  impaction  of  the  intestinal 
canal,  from  the  use  of  pills  containing,  each,  /jj  of  a  grain  of 
sulphate  of  strychnia  with  ^It?  of  a  grain  of  sulphate  of  atropia, 
given  thrice  daily.  Most  authorities  agree  that  little  or  no  food 
or  drink  should  be  given  by  the  mouth ;  nourishment  being 
administered  by  enemata  of  beef-tea,  milk,  etc.  Besides,  we 
may  try  large  enemata  of  warm  water;  or  inserting  a  bougie;  or 
a  stomach-tube,  to  catheterize  the  bowel,  as  far  as  the  ileo-csecal 
valve ;  or,  the  Hippocratic  remedy  of  large  air  injection,  to  dis- 
tend and  dislodge  the  intestine.  Dr.  R.  Battey  {Atlanta  Med. 
and  Surg.  Journal,  June,  1874)  urges  the  persistent  use  of  disten- 
sile  enemata  of  from  ten  to  twenty  or  more  pints  of  water.  Gus- 
tav  Simon  and  Mosler  also  have  advised  the  slow  introduction 
of  from  five  to  nine  pints  of  fluid  at  a  time.  This  has  succeeded 
in  several  cases  of  intussusception.  Kneading  the  bowels  gently 
while  the  patient  is  upon  his  hands  and  knees,  and  under  the 
influence  of  ether  (Lambl,  S.  Rogers,  Burrall),  is  sometimes 
successful.  Scfijbala  or  impacted  feces,  coagula,  etc.,  may  be 
removed  by  a  spoon  or  scoop  from  the  rectum.  Galvanism  has 
sometimes  restored  interrupted  pei'istaltic  action.  The  applica- 
tion of  the  continuous  current  has  been  very  favorably  reported 
upon  by  a  number  of  practitioners  in  France  (1879).  Prolonged 
use  of  the  warm-bath  may  be  tried,  to  relax  the  system  ;  and,  as 
in  strangulated  hernia,  the  tobacco  injection  may  be  allowable  as 
an  extreme  resort.  On  the  other  hand,  M.  Pyronac  {Gazette  des 
H<'q)itaux^  1871)  reports  the  recovery  of  a  case  under  the  appli- 
cation of  ice  to  the  abdomen,  and  injections  of  ice-water  every 

1  See  Bryant's  Surpery,  Am.  Edition,  p.  454,  or  Reynolds'  System  of  MedicinCj  vol.  ill., 
p.  191,  for  a  table  of  Diagnostic  Signs  in  Abdominal  Obstruction. 
^  2  Downes,  Lancet,  Dec.  4,  1880. 


286        DISEASES   OF   OEGANS   OF   DIGESTION. 

quarter  of  an  hour.  Dr.  F.  H,  Hamilton  speaks  well  (Hospital 
G-azette,  N.  Y.,  Jan.  3,  1880)  of  the  effects  of  posture;  elevating 
the  hips.  Nuck,  long  ago,  used  abdominal  traction,  by  an  immense 
cup  and  pump.  An  instrument  lately  contrived  by  myself  (in- 
tended to  produce  diaphragmatic  respiration  in  cases  of  asphyx- 
ia) may  answer  the  same  purpose.  It  is  a  large  syringe  or  hand 
pump  connected  with  a  metallic  cup,  six  inches  across  at  its  edge, 
to  be  applied  to  the  abdomen.  K.  Duplouy  [Gaz.  Hebd.,  Eeb., 
1871)  in  a  case  of  strangulated  hernia,  obtained  relief  by  punctur- 
ing the  intestine  with  a  needle,  and  withdrawing  the  gas  by 
means  of  a  respiratory  syringe.  Other  like  successes  have 
occurred,  with  Dieufaloy's  aspirator.  Broadbent  ^  has  shown  that 
caution  is  necessary  with  this  procedure.  1.  An  opiate  or  hypo- 
dermic injection  of  morphia  should  precede  it,  to  restrain  peri- 
staltic movement.  2.  A  portion  of  gut  should  be  chosen  which 
contains  only  gas,  not  liquid  ;  great  danger  attending  the  escape  of 
the  latter  into  the  peritoneum.  Most  favorable,  usually,  will  be 
the  choice  of  the  jejunum,  above  the  umbilicus.  3.  The  perfora- 
tion must  be  made  at  the  most  convex  part  of  the  intestine.  4. 
The  needle  must  be  steadily  held  while  gas  escapes  from  it ;  this 
may  be  promoted  by  gentle  pressure  and  manipulation.  Such 
an  operation  is,  mostly,  rather  palliative  or  auxiliary  than  cura- 
tive of  existing  obstruction.  Annandale^  recommends  gastrot- 
omy  (abdominal  section)  in  sudden  and  complete  obstruction  not 
relieved  by  ordinary  treatment.  He  advises  that  the  operation 
should  not  be  delayed  beyond  thirty-six  or  forty -eight  hours  after 
the  first  symptoms  appear ;  that  the  abdomen  should  be  opened 
on  the  middle  line,  the  best  guide  to  the  seat  of  obstruction  being 
the  contracted  or  dilated  condition  of  a  part  of  the  intestine.  If 
the  bowel  be  gangrenous,  or  the  obstruction  not  removable,  the 
canal  may  be  opened,  and  an  artificial  anus  established. 

J.  Hutchinson^  reports  a  successful  case  of  gastrotomy  (1873). 
When  the  colon  is  the  seat  of  obstruction,  Calliser,  Amussat, 
Clement,'*  and  others  have  shown  that  colotomy  (in  the  right  loin 
(N^laton^)  if  the  obstruction  be  above  the  rectum)  is  a  justifiable 
operation.  It  is  also  least  dangerous  when  not  too  long  delayed. 
Laparotomy  (instead  of  gastrotomy)  is  the  term  applied  by  some 
authors  to  abdominal  section,  as  an  exploratory,  and  when  pos- 
sible, a  remedial  operation,  especially  for  intussusception.  Dr.  J. 
Ashhurst  has  tabulated  {Am.  Journal  of  Med.  Sciences,  July,  1874) 
thirteen  such  operations  for  intussusception,  with  five  recoveries ; 
also,  fifty-seven  similar  operations  for  other  forms  of  intesti- 
nal obstruction,  with  eighteen  recoveries.  Bulteau*  collected 
ninety-two  instances  of  laparotomy  for  intestinal  obstruction,  in 
which  33  or  36  per  cent,  were  followed  by  recovery.  An  impor- 
tant argument  in  favor  of  laparotomy  as  compared  with  colotomy 
is,  that  it  gives  opportunity  for  exploration,  before  further  inter- 
ference is  ventured  upon ;  diagnosis  of  the  nature  of  the  obstruc- 
tion by  mere  external  inspection  being  often  extremely  difficult ; 
sometimes  impossible.     Dr.  Pyle,  of  Nashville,  performed  lapa- 

1  Brit.  Med.  Journal,  ii.,  1879,  p.  490.  <  Medico-Chirurg.  Transactions,  vol.  xxxv. 

2  Ediii.  Med.  Journal,  February,  1871.         6  Littre  (1710)  operated  in  the  left  iliac 
8  Med.  Times  and  Gazette,  Kov.  29,  1873.    »  Th6se  de  Paris,  1880.  [region. 


CHOLERA     MORHUS.  287 

votomy  succcssfiiUy  for  intussusception,  in  1870.'  Treatment  of 
slrkture  of  the  bowel  in  a  manner  similar  to  that  en)ploycd  for 
die  cure  of  stricture  of  the  urethra,  i.  c,  by  incision  and  sub- 
sequent moderate  dilatation,  has  much  argument  in  its  favor. 
Several  surgeons  have  nicked  the  strictured  part.  Dr.  F.  Lente^ 
has  practised  free  incision  with  success,  in  the  median  line,  with 
precautions  against  henu)rrhage.  VerneuiF  also  has  performed 
the  same  operation  upon  the  rectum.  lie  advises  only  a  i^os- 
terior  incision,  which  is  probably  the  safest. 

CHOLERA  MORBUS. 

This  very  unscientific  name  has  become  inseparably  attached 
to  what,  in  technical  phrase,  may  be  most  briefly  called  idiopathic 
(mcto-catharsis;  i.  e.,  vomiting  and  purging,  neither  brought  on 
by  irritant  poison  nor  by  epidemic  influence.  The  account  which 
I  shall  give  applies  best  to  such  an  affection  as  we  commonly 
meet  with  in  this  country,  especially  in  the  summer.  English 
medical  writers  describe  it  sometimes  as  English  cholera;  or 
sporadic  cholera. 

Symptoms.— Nausea,  and  vomiting  of  greenish  or  yellowish 
fluid,  with  rejection  of  all  food  and  drink  ;  often,  but  not  always, 
pnin  in  the  stomach  and  bowels ;  diarrhoea,  with  brownish  or 
yellowish  stools  ;  debilit}',  and  coldness  ;  little  or  no  fever.  Begin- 
ning with  such  symptoms,  if  the  attack,  not  relieved,  becoines 
aggravated,  cramps  in  the  limbs  supervene,  the  vomiting  and 
purging  become  more  watery  ;  prostration  and  coldness  deepen 
into  collapse— which  may  be  fatal. 

Causation. — Warm  weather  seems  to  predispose  to  it,  by  relax- 
ing the  mucous  membranes  and  exciting  the  liver.  Direct  causes 
often  are,  indigestible  articles  of  food,  as  unripe  fruit,  etc.  ;  excess 
of  ordinary  food ;  sudden  change  of  temperature,  checking  per- 
si^iration. 

Diagnosis. — Erom  epidemic  cholera,  it  is  important  to  dis- 
tinguish cholera  morbus ;  as  the  prognosis  is  not  the  same,  nor 
will  the  same  treatment  answer  for  both.  The  difference  is  seen 
in  the  bilious  vomiting  and  purging  of  cholera  morbus,  and  the 
ricc-icater  discharges  of  cholera;  the  greater  nausea  in  the  former; 
much  more  tendency  to  collapse,  with  blueness,  dyspnoea,  and  sup- 
pression of  urine,  in  cholera.  The  presence  or  absence,  at  the 
time,  of  an  epidemic  of  the  latter  may  complete  the  diagnosis 
by  confirming  or  correcting  the  evidence  of  the  above  signs.  It 
is  only  in  an  extreme  case  of  cholera  morbus  that  any  real  diffi- 
culty should  exist.  During,  and  before  and  after,  the  prevalence 
of  epidemic  cholera,  an  especial  tendency  to  cholera  morbus  as 
well  as  diarrhoea  often  exists.  This,  called  cholerine,  niay  pre- 
sent more  near  resemblance  to  malignant  cholera  than  our  ordi- 
nary summer  attacks. 

Treatment. — A  large  sinapism  should  be  at  once  placed  over 
the  epigastrium.     All  theory  or  rationale  apart,  the  following 

1  Nashville  Journal  of  Med.  and  Surgery,  January,  1880. 

2  Am.  Journal  of  Med.  Sciences,  July,  1873,  p.  23. 
*  Gazette  MOdicale  de  Paris,  Jan.  4, 1873. 


288        DISEASES    OF    ORGANS   OF   DIGESTION. 

mixture,  largely  employed  in  the  practice  of  the  iate  Dr.  Joseph 
Hartshorne,  is  admirably  useful  in  ordinary  summer  cholera 
morbus : 

R.   Sp.  ammon.  aromat.  f^j. 
Magnes.  optira.  J5j. 
Aquffi  menthse.  piperitse,  f  .^iv. — M. 
To  be  shaken  when  taken. 
S. — A  teaspoonful  every  twenty  minutes. 

Few  cases  will  fail  to  be  relieved  in  an  hour  or  two,  if  this  be 
given  early. 

When  the  diarrhoea  is  copious,  or  the  case  is  seen  rather  late, 
paregoric  may  be  added  to  the  above —  f  5ij  or  f  Sss,  in  the  same 
mixture.  When  purging  is  very  urgent  and  exhaustive,  instead 
of  magnesia  a  like  amount  of  bicarbonate  of  sodium  may  be  used. 
Infusion  of  cloves,  cinnamon,  or  ginger,  may  assist  to  quiet  the 
stomach  in  an  obstinate  case.  After  the  sinapism,  a  spice  poul- 
tice, of  ginger,  cloves,  and  cinnamon,  eacli  a  full  teaspoonful, 
with  a  tablespoonful  of  flour,  moistened  with  whisky,  should  be 
applied.     Ice  may  be  given  if  thirst  be  great. 

Extreme  prostration  may  require  the  use  of  brandy  or  whisky 
internally.  To  check  the  diarrhffia  and  vomiting  when  threat- 
ening collapse,  a  laudanum  and  starch  enema  (40  to  60  drops 
of  laudanum  in  ^  ounce  of  starch)  may  be  given ;  and  a  blister 
may  be  applied  over  the  stomach,  the  part  to  be  dressed,  when 
vesicated,  with  2  grains  of  acetate  of  morphia  mixed  with  10  of 
powdered  gum  arable ;  or  the  hypodermic  injection  of  morphia 
may  be  used. 

Winter  Cholera. — During  the  very  cold  winter  of  1880-81, 
there  occurred  in  Chicago  and  some  other  western  cities  many 
cases  of  an  affection  resembling  cholera  morbus,  but  with  some 
peculiarities ;  besides  the  exceptional  fact  of  their  taking  place 
in  the  winter  instead  of  the  summer.  The  following  account  is 
taken  from  a  report  in  the  National  Board  of  Health  Bulletin 
(March  12,  1881): 

"The  two  features  that  have  attracted  attention  in  this  affec- 
tion are  the  severity  of  the  vomiting  and  the  copious  discharges 
from  the  bowels. 

"  The  matters  rejected  from  the  stomach  have  usually  given 
slight  acid  reaction,  at  the  first  consisting  mainly  of  aliment 
and  drinks,  readily  rejected,  and  then  mucous  secretion  from 
the  stomach,  sometimes  tinged  with  bile,  sometimes  not.  The 
alvine  evacuations  have  been  markedly  of  a  serous  character ;  a 
fact  specially  noted.  In  some  cases  the  typical  appearance  of 
bilious  diarrhoea,  giving  the  stool  a  bright  yellow  color,  in  others 
an  absence  of  bile.  The  discharges  varying  from  a  bright  creamy 
color  to  those  characteristic  of  cholera,  only  that  in  them  I  have 
not  noticed  coagulated  albumen. 

"  The  urine  is  usually  rather  scanty  and  high  colored  until  the 
diarrhoea  is  controlled. 

"  The  nervous  system,  aside  from  the  sense  of  prostration,  does 
not  seem  to  manifest  disturbance. 

"The  mucous  secretion  is  partially  arrested  in  the  respiratory 
passages,  and  especially  in  the  mouth  and  fauces. 


DIARRIICEA.  289 

"  The  capillaiy  circulation  of  tlie  skin  varies,  but  there  is  no 
uniform  marked,  disturbance  of  the  circulation. 

"  The  sul)jective  symptoms  arc,  in  the  order  of  their  severity — 

"1.  Inoi-dinate  thirst,  with  dryness  of  tongue  and  fauces. 

"2.  More  or  less  frequently  occurring  nausea,  with  vomiting. 

"  3.  Tenderness  over  umbilical  region  covering  region  of  small 
intestines. 

"4.  Quite  frequently  a  sense  of  fulness  and  pain  in  the  region 
of  the  liver,  with  sometimes  excessive  secretion,  and  at  others 
seeming  congestion,  with  arrest  of  biliary  secretion. 

"5.  Fugitive  pains  in  various  parts  of  the  body." 

In  the  practice  of  some  physicians  the  choleraic  discharges 
were  not  observed,  all  the  stools  being  characterized  simply  by 
the  absence  of  bile.  The  implication  of  the  liver  function  was 
a  very  common  feature,  and  jaundice  was  produced  in  some  of 
the  severer  cases. 

The  onset  of  the  disease  was  usually  sudden ;  patients  in  some 
extreme  cases  on  rising  in  the  morning  felt  only  a  slight  dryness 
in  the  mouth,  but  found  themselves  unable  to  keep  even  a  drink 
of  water  on  the  stomach.  Generally,  however,  the  onset,  though 
sudden,  was  not  so  abrupt  as  this. 

The  duration  of  the  disease  was  very  variable — many  even  of 
the  severer  cases  recovered  within  a  few  days,  sometimes  within  a 
fewhours  under  prompt  treatment;  others  have  lastedmany  weeks. 

As  after-eftects,  there  have  been  observed,  besides  the  jaundice 
already  mentioned,  subacute  enteritis,  d3^senter5'',  and  ulceration 
of  the  rectum.  In  most  cases  a  tendency  to  relapse  was  observed, 
and  changes  of  weather  were  very  influential  in  bringing  this 
about,  as  well  as  influencing  the  course  of  the  disease  during 
its  existence.  Imprudence  and  exposure  generally  were  thought 
to  produce  it  or  to  aggravate  it. 

During  the 'earlier  weeks  of  the  epidemic  the  disease  appeared 
to  be  mostly  confined  to  adults,  but  later  children  were  also  at- 
tacked to  some  extent,  the  trouble  in  them  often  taking  the  form 
of  cholera  infantum.  Very  few  deaths  resulted  directly  from 
this  disease.  It  was  treated  upon  general  principles,  according 
to  the  symptoms  ;  mostly  with  opiates  and  mineral  astringents. 

DIARRHffiA. 

Though  rather  a  symptom  than  a  disease,  excessive  discharge 
from  the  bowels  often  requires  express  treatment  for  its  relief. 

Varieties. — These  are,  principally,  1.  Irritative  diarrhoea,  as 
from  dentition ;  2.  Inflammatory,  as  in  enteritis ;  3.  Symptom- 
atic, as  in  typhoid  fever ;  4.  Critical,  as  at  the  close  of  remittent 
fever;  5.  Eliminative,  as  in  septic  or  other  poisoning;  6.  Col- 
liquative, as  in  phthisis. 

The  character  of  the  discharges  varies  very  much.  They  may 
be,  1.  Fecal,  although  liquid ;  2,  Bilious ;  3.  Mucous ;  4.  Serous ; 
5.  Adipose  (very  rare'). 

'  Bidie  found  fat  in  the  passages  of  soldiers  suffering  from  diarrhoea  in  India.  Wood- 
•vrard  (Med.  Report  of  War  of  the  Rebellion,  Part  II.)  quotes  authors  who  have  observed 
fatty  discharges  in  cn.sea  of  diabetes  mellitus,  phthisis,  typhoid  fever,  cholera,  and  chrouic 
intestinal  disorders  of  children. 

25  T 


290        DISEASES   OF  ORGANS  OF   DIGESTION. 

Except  in  the  beginning  of  attacks,  discharges  are  rarely  fecal 
in  character  when  much  beyond  the  normal  amoant.  The  gutter- 
water  discharges  of  typhoid  fever  often  have  nearly  the  fecal 
appearance  except  in  consistence.  Mucous  discharges  occur  in 
enteritis,  and  in  many  cases  of  summer  diarrhoea.  Bilious  pas- 
sages occur  in  cholera  morbus.  Serous,  or  "rice-water,"  in 
malignant  cholera.     Bloody  discharges,  in  dysentery. 

Treatment. — An  important  point  is,  that  in  many  cases  diar- 
rhoea ought  not  to  be  abruptly  checked  ;  in  some  it  should  not  be 
interfered  with  at  all.  The  latter  is  true  of  the  looseness  of  the 
bowels  in  typhoid  fever,  if  the  passages  are  not  more  than  three 
daily,  and  are  but  moderate  in  amount.  When  excessive  in  that 
disease,  they  require  checking,  not  arresting. 

Ordinary  summer  diarrhoea,  the  most  nearly  "idiopathic  "  of  all 
forms,  demands  correctives,  generally  before  or  with  astringents. 
Blue  mass  or  hydrargyrum  cum  creta ;  magnesia,  with  charcoal 
or  with  aromatic  syrup  of  rhubarb  [F.  101] ;  bicarbonate  of  sodium, 
with  ginger  or  cinnamon,  etc.,  or  charcoal  (Guerin)  alone  will  often 
relieve  the  condition  of  the  alimentary  canal  in  which  diarrhoea 
originates,  and  thus  end  it  without  the  use  of  any  astringents. 

When  the  latter  are  indicated  by  continuance  or  increase  of 
the  discharges,  chalk  mixture  has  long  held  a  routine  place  as  an 
early  prescrij)tion.  Instead  of  it  some  prefer  testa  jprmjjaraia  or 
OGuli  cancrorum.  In  infants,  lime-water,  with  cinnamon  or  cam- 
phor-water, will  do  for  mild  cases.  Kino,  catechu,  krameria,  and 
hsematoxylon  are  familiar  as  pure  astringents.  The  addition  of 
opium,  or  camphor,  or  both  (as  in  paregoric)  in  smaU  doses  to 
such  preparations  is  generally  proper,  to  increase  the  binding 
effect,  even  in  the  absence  of  pain  [F.  102,  103,  104] . 

Drs.  Toner  and  J.  J.  Warner  have  (1873)  called  the  attention 
of  the  profession  to  the  experience  of  residents  of  California 
with  the  root  of  Anemopsis  Galifornica  (a  low  herbaceous 
perennial  plant)  as  a  remedy  for  diarrhoea.  During  infancy. 
Dr.  Brakenridge^  advises  oxide  of  zinc  for  frequent  diarrhoea,  as 
a  nervous  tonic  as  well  as  a  mild  astringent  medicine.  The  coto 
bark  of  S.  America  is  found  useful  in  doses  of  from  5  to  8  minims 
of  the  fluid  extract,  in  exhausting  diarrhoea  (Groit,  FronmuUer, 
J.  Burney  Yeo).  Coto  has  the  advantage  of  not  being  a  narcotic, 
and  of  being  rather  tonic  than  depressing  to  the  stomach.^  Dr. 
Messemer,^  of  ^ew  York,  obtained  several  recoveries  from  chronic 
diarrhoea  by  injections  of  cold  water,  repeated  after  each  passage 
from  the  bowels. 

In  infantile  diarrhoea,  when  obstinate,  Drs.  ITewell  and  Tyson,* 
of  Philadelphia,  have  found  good  effects  to  result  from  injections 
into  the  bowels  containing  each  2  grains  of  hydrate  of  chloral  in 
2  teaspoonfuls  of  starch. 

Dr.  Comegys,  U.  S.  A.,  has  had  excellent  results  in  diarrhoea 
from  fluid  extract  of  ergot,  in  20  to  40-drop  doses. 

Obstinate  cases  should  be  treated  with  tannin  (gr.  iij  in  pill, 

1  Med.  Times  and  Gazette,  Feb.  15, 1873. 

2  Bhone,  Virginia  Med.  Monthly,  March,  1881. 

3  Am.  Journal  of  Med.  Sciences,  July,  1878,  p.  133. 
i  Philadelphia  Med.  Times,  Sept.  14,  1878. 


CHOLERA    INFANTUM.  291 

with  .'  or  i  grain  of  opium,  xtm  rr  nata),  or  pills  of  acetato  of  lead 
and  opium  (gr.  j  of  the  acetate,'with  gr.  ^  of  opium)  every  three  or 
four  hours  ;  or  a  mixture  containing  acetate  of  lead  with  acetate 
of  morphia  ;  aided  when  necessary  by  enemata  of  laudanum  and 
starch  (30  to  (iU  drops  of  laudanum  to  I  ounce  of  starch  cool  or 
cold).  As  an  article  of  diet  in  feeble  cases,  arrowroot,  with  milk 
and  a  small  amount  of  brandy,  will  be  especially  suitable. 

In  chronic  diarrhoea,  besides  the  remedies  last  mentioned, 
sometimes  enemata  of  acetate  of  lead  solution,  or  of  some 
other  mineral  astringent,  will  do  good.  Mention  of  these  will 
be  again  made  in  connection  with  chronic  dysentery. 

The  food  in  cases  of  diarrhoea  always  requires  regulation. 
Vegetables  and  fruits,  as  a  rule,  ouglit  to  be  forbidden ;  the 
popular  prejudice  which  makes  the  blackberry  an  exception  I 
believe  to  be  a  mistake.  It  has  had  its  origin  in  the  known 
astringency  of  the  root.  Boiled  rice,  and  other  farinacea,  will 
nearly  always  be  suitable.  In  severe  cases,  all  solid  articles  of 
food  should  be  withheld. 

Scorbutic  diarrhoea,  however,  from  the  nature  of  its  cause, 
demands  a  quite  diflerent  regimen.  Officers  in  the  army  who 
were  aflected  with  diarrhoea  on  the  Chickahominy  in  McClellan's 
campaign,  told  me  that  when  astringents  had  no  effect  in  check- 
ing the  complaint,  tomatoes,  peaches,  and  lemonade  cured  it  at 
once.  I  saw  the  same  thing  occur  in  a  number  of  cases  in  army 
hospital  practice  in  1862. 

CHOLERA  INFANTUM. 

Popularly  known  as  '■^summer  compJaint^''^  this  affection  is  very- 
destructive  to  young  children  in  the  large  cities  of  this  country,  in 
hot  weather.  The  peculiar  influence  of  high  heat  in  an  atmos- 
phere contaminated  by  "town"  causes,  generates  it.  In  ISTew 
York  and  Philadelphia,  its  prevalence  and  mortality  coincide  with 
the  rise  of  the  thermometer  above  90°  F.  in  the  shade.  The 
deaths  from  all  causes  for  the  hottest  week  in  July,  1806,  in  New 
York,  were  over  1200,  and  in  Philadelphia  over  700  ;  more  than 
occurred  in  a  single  week  in  either  city  during  the  prevalence  of 
cholera  later  in  the  same  season,  and  more  than  twice  the  usual 
mortality.  In  1872, 1659  deaths  from  cholera  infantum  occurred 
in  Philadelphia. 

Symptoms. — These  are  diarrhoea,  vomiting,  rejection  of  food, 
languor,  debility,  apathy  ;  sometimes  stupor.  At  first  the  head 
may  be  hot,  the  abdomen  swollen  ;  as  the  case  progresses,  cold- 
ness and  emaciation  supervene.  In  some,  with  predominance  of 
cerebral  symptoms,  death  may  be  threatened  after  a  very  few 
days  of  sickness.  In  others,  copious  diarrhea  and  constant 
vomiting  endanger  the  same  result.  In  many,  however,  without 
violent  symptoms,  the  child  is  gradually  reduced  by  diarrhoea  and 
inanition.  The  period  of  dentition  is  particularly  liable  to  this 
disorder ;  it  seldom  occurs  after  two  or  three  years  of  a;^e. 

Pathology.— Although  decided  alteration  of  the/o?ZicTes  of  the 
intestines,  with  some  change  in  the  general  appearance  of  the 
mucous  membrane,  has  been  shown  to  be  generally  present  after 
death  from  cholera  infantum,  the  disease  is  most  probably  rather 


292        DISEASES  OF   ORaANS   OF  DIGESTION. 

a  systemic  than  a  local  one.  Its  seat  must  be  in  the  whole  nutri- 
tive apparatus,  including  the  ganglionic  nerve-centres.  Sanguifi- 
cation is  evidently  impaired,  and  an  imperfect  blood  deranges  the 
action  of  the  brain  and  spinal  cord  ;  hence  the  stupor,  or  extreme 
apathy,  and  in  some  bad  cases,  convulsions.  I  cannot  see  the 
propriety  of  excluding  (as  is  done  by  Meigs  and  Pepper,  and  others) 
all  cases  from  the  category  of  cholera  infantum  except  those 
having  the  character  of  extreme  collapse,  resembling  epidemic 
cholera.  The  term  cholera  was  used  by  the  Greeks  to  mean  a 
copious  watery  discharge  from  the  towels^  long  before  Asiatic  cholera 
was  known.  In  regard  to  its  local  pathological  anatomy,  cholera 
infantum  appears  to  be  a  catarrhal  enterocolitis.  The  large  intes- 
tine is  chiefly  but  not  exclusively  involved.  Kedness  and  turges- 
cence  are  found  after  death  particularly  near  the  sigmoid  flexure 
of  the  colon.  Sometimes,  in  bad  and  prolonged  cases,  round 
ulcers  occur  in  the  descending  colon.  With  or  without  ulceration, 
the  solitary  intestinal  glands  are  commonly  enlarged  and  softened 
in  both  the  large  and  the  small  intestines  ;  the  agrainated  glands 
also,  not  unfrequently.  Whether  the  whole  of  the  alteration  of 
these  glands  is  most  correctly  indicated  by  the  term  inflamma- 
tion, is  a  question  of  pathology  which  we  have  not  room  here  to 
consider.^ 

Treatment. — Oorreciives  are,  here,  especially  important  in  the 
beginning.  I  am,  from  considerable  experience,  a  full  believer  in 
the  value  of  moderate  doses  of  calomel  in  the  early  stages  of 
summer  complaint.  I  would  always  give  it  with  an  antacid  [F. 
107].  When  stomach  or  head  symptoms  predominate,  with  but 
little  diarrhoea,  calomel  with  magnesia  will  do  the  best.  When 
there  is  more  looseness,  bicarbonate  of  sodium  should  be  used, 
with  the  calomel,  instead.  Spiced  syrup  of  rhubarb  may  be  added 
to  either.  Hydrargyrum  cum  cret^  is  the  preferred  mercurial 
with  many  practitioners.  I  have  found  it  to  answer  very  well, 
after  or  even  perhaps  instead  of  calomel.  J.  Lewis  Smith,  Jacobi, 
and  Banks'*  recommend  subnitrate  of  bismuth. 

A  spice  poultice  or  plaster  should  be  kept  over  the  abdomen  so 
long  as  vomiting  continues  ;  being  renewed  or  wet  freshly  with 
brandy  or  whisky  often  enough  to  maintain  its  strength.  Ice 
(pounded  in  a  rag  for  young  infants)  may  be  given  more  often  than 
water  to  quench  thirst.  The  food  may  be  lime-water  and  fresh 
milk,  arrowroot,  farina,  chicken-water,  beef-tea.  It  is  of  the 
greatest  consequence  that  the  milk  given  to  the  infant  shall  be 
fresh  and  good  ;  in  hot  weather,  a  few  hours  will  spoil  it,  even 
before  it  becomes  sour.  Barley-water  may  be  added,  when  the 
digestion  of  casein  is  shown  to  be  imperfect  by  the  passage  of 
curds  in  the  stools.  Excessive  dilution  of  milk  given  to  young 
infants  is  always  to  be  avoided.  For  an  infant  under  two  months 
of  age,  one-third  of  its  bulk  of  water  or  barley-water  may  be 
added  to  the  milk ;  under  six  months,  one-fourth ;  after  that 
time,  it  may  be  generally  given  undiluted. 

When  milk  seems  not  to  agree  with  the  patient,  even  with 

iSee  J.  J.  Woodward,  Medical  History  of  the  War,  Part  II.,  p.  325. 
SFiske  Fuud  Prize  Essay  ou  Cholera  Infantum,  1879;  p.  29. 


CHOLERA     INFANTUM.  298 

barley-water  and  lime-water  added,  wo  may  try  ricc-wateA',  made 
thick,  and  added  to  milk  in  tHe  proportion  of  two  parts  to  one  of 
the  latter.  Or,  often  still  better,  put  a  qviantity  of  wheat  flour 
into  a  bag,  and  boil  it  for  several  hours  ;  then  dry  the  mass,  grate 
it,  and  mak(>  a  gruel  of  it,  to  be  mixed  in  equal  parts  with  milk. 
Meigs  and  Pepper  highly  recommend  gelatin  food  (see  Di£tary 
Prepurntionti,  at  the  end  of  the  book).  After  the  first  stage, 
many  children  will  require  small  quantities  (drops,  not  drachms) 
of  brandy  or  whisky  (preferably  with  their  food)  for  support. 
Kjellberg '  asserts  that  cncmata  of  from  four  to  eight  grains  of 
hydrate  of  chloral,  with  one  drop  of  laudanum,  in  a  dessert-spoon- 
ful of  liquid  (as  starch  or  mucilage)  will  often  arrest  the  vomiting. 

In  the  early  stage,  if  the  head  continue  to  be  hot  and  stupor  be 
threatened,  a,  few  leeches  behind  the  ears,  and  the  application  of 
cold  water,  upon  a  light  cambric  handkerchief,  to  the  head,  may 
sometimes  be  proper.  Such  a  stage,  however,  does  not  often  last 
long.  The  tepid  or  even  cool  bath  (Comegys  '■^),  also,  may  do  excel- 
lent service,  repeated  every  day.  Dr.  J.  L.  Smith  sometimes 
keeps  down  the  temperature  with  Kibbee's  fever  cot. 

Later,  the  two  difficulties  are,  to  check  the  diarrhoea,  and  to 
overcome  the  rejection  of  food  by  the  stomach.  For  the  bowels, 
astringents  are' then  called  for;  especially  logwood,  blackberry 
root,  geranium,  krameria,  aromatic  syrup  of  galls  ;  aided  in 
serious  cases  by  paregoric  in  small  quantities  by  the  mouth,  or 
even  the  injection  into  the  bowels  of  one,  two,  or  three  drops  of 
laudanum  with  starch.  Sometimes  acetate  of  lead  injections 
(from  one  to  three  grains,  with  starch)  may  be  needed  for  the 
same  intent.  Acetate  of  lead  with  acetate  of  morphia,  in  muci- 
lage with  cinnamon-water,  makes  a  useful  combination  in  obsti- 
nate cases.  Nitrate  of  silver,  in  ^V  of  a  grain  doses,  thrice  daily, 
has  sometimes  an  excellent  effect]^  Dr.  H.  L.  Byrd  advises  sul- 
phite of  sodimn;  1  or  "2  grain  doses.  Dr.  Boardman  Reed^  has 
obtained  good  results  with  small  doses  of  corrosive  sublimate. 
Dr.  J.  L.  femitli  gives  morphia  and  quinine  hypodermically. 

Protracted  summer  complaint  aflbrds  scope  for  perseverance  and 
contrivance  in  finding  food  available  for  the  child.  Well-made 
beef-tea  agrees  with  most  children.  Frozen  beef-tea  (proposed  by 
Dr.  H.  B.  Hare,  of  Philadelphia)  is  especially  likely  to  be  accept- 
able. Raw  beef  scraped  or  rasped  fine,  has  been  found  to  answer 
the  purpose  best  with  some. 

But  all  medical  treatment  may  fail  in  some  cases  of  cholera 
infantum,  which  will  speedily  recover  on  being  removed  from  the 
city  to  the  country.  The  immediate  effect  of  a  salubrious  air  is 
often  surprising  and  delightful. 

Prophylaxis. — This  is  very  clear  and  simple.  A  child  under 
five  years  of  age  ought  never  to  be  kept  in  the  close-built  parts  of 
a  large  city,  in  our  climate  at  all  events,  through  June,  July,  and 
August,  if  it  can  be  helped.  Next  to  a  residence  for  the  summer 
in  a  high  and  open  country,  will  be  the  benefit  of  frequent  excur- 
sions or  visits  ;  riding  or  sailing  ;  or  even,  if  nothing  else  be  pos- 

1  Amer.  Practitioner,  June,  1880. 
2N.  Y.  Med.  Record,  June  29,  1876. 
3  Phila.  Med.  Times,  Jan.  ai,  1880. 

25* 


294        DISEASES    OF   ORGANS    OF    DIGESTION". 

sible,  being  carried  daily  into  the  squares  or  parks  of  the  city. 
The  proposition  to  have  estabhshed  summer  camps,  outside  of 
each  of  our  large  cities,  as  places  of  refuge  for  the  children  of  the 
poor  during  the  hottest  weather,  is  a  very  reasonable  one.  Im- 
mense good  has  been  done  in  Philadelphia,  New  York,  and  Balti- 
more by  children's  sanitaria  at  the  seaside  or  elsewhere  out  of 
town,  and  by  the  "  country  week  "  charity,  by  which  poor  infants 
are  boarded  (with  their  mothers  if  necessary)  for  a  week  or  two 
at  a  time  in  the  country  during  hot  weather.  A  decided  reduc- 
tion in  the  annual  summer  infantile  mortality  of  those  cities  has 
already  been  effected  by  these  and  kindred  improvements. 

DYSENTERY, 

Definition. — An  inflammation  of  the  large  intestine,  involving 
the  muscular  as  well  as  the  mucous  coat. 

Varieties, — Acute  and  chronic  ;  sthenic  and  asthenic  ;  endemic 
or  epidemic  ;  bilious  ;  ulcerative  ;  strumous  or  tuberculous. 

Symptoms, — Pain  in  the  lower  half  of  the  abdomen,  with  sore- 
ness or  tenderness  on  pressure  or  motion ;  frequent  disposition  to 
go  to  stool,  with  small  and  bloody  or  blood-marked  muco-fecal  or 
mucous  passages,  sometimes  containing  shreds  of  lymph  or  false 
membrane  ;  tendency  to  strain  (tenesmus)  with  griping  (tormina); 
fever  in  most  acute  cases. 

Severe  and  protracted  cases  maybe  considered  as  going  through, 
first,  the  inflammatory,  and  second,  the  ulcerative  stages. 

Simple  acute  dysentery  is  commonly  sthenic,  or  open,  active, 
and  inflammatory,  without  early  or  great  tendency  to  prostra- 
tion. Endemic  or  epidemic  dysentery  (the  first  name  is  the  more 
correct)  is  generally  asthenic.  In  this  form  fever  may  be  absent, 
brief,  or  of  a  typhoid  character.  Vomiting  is  not  rare  in  this,  as 
it  is  in  the  ordinary  acute  form.    Coldness  and  debility  come  early. 

Sometimes,  in  malarial  districts,  dysentery,  like  all  other  mala- 
dies, may  be  intermittent ;  with  daily  or  tertian  exacerbations  and 
intervals. 

Morbid  Anatomy. — Redness,  turgescence,  thickening,  soften- 
ing, ulceration,  suppuration,  and  occasionally  pseudo-membranous 
deposits,  are,  after  death  from  dysentery,  found,  in  various  de- 
grees, in  the  rectum,  colon,  caecum  ;  chiefly  in  the  lower  bowel. 
Pigment  deposits  have  been  found  especially  in  scorbutic  dysen- 
tery, in  the  villi  of  the  small  intestine,  and  in  the  patches  of 
Peyer ;  giving  the  peculiar  "  shaven  beard  "  appearance  of  that 
affection.  The  hemorrhage  which  makes  the  typical  bloody  stools, 
is  due  to  the  congested  and  inflamed  mucous  membrane  being 
constricted,  in  the  tenesmus,  by  spasmodic  and  irregular  con- 
tractions of  the  muscular  coat.  Abscess  of  the  liver  is  not  very 
uncommon. 

Chronic  dysentery  presents  nearly  always  ulceration  of  the 
rectum  or  colon,  or  both.  The  discharges  in  this  may  become 
almost  entirely  muco-purulent. 

Causation. — Predisposition  to  dysentery  is  common  in  the  latter 
part  of  summer ;  in  Philadelphia  and  its  neighborhood,  from  the 
middle  of  August  to  the  end  of  September,  especially.     Relaxa- 


DYSENTERY.  295 

tion  from  heat,  with  sudden  exposure  to  cold  and  wet,  may  pro- 
duce an  attack.  80,  often,  will  indigestible  food  ;  as  unripe  fruit. 
Bad  drinking-water  is  another  cause. 

At  any  season  and  locality  such  agencies  may  produce  simple 
acute  dysentery.  But  in  certain  regions  it  becomes  at  times 
endemic.  This  is  particularly  noticed  in  many  localities  having 
considerable  elevation,  not  subject  to  malarial  fevers,  but  within 
a  short  distance  of  ague  districts  ;  dysentery  upon  or  among  the 
hills,  while  intermittent  and  remittent  occur  in  the  adjoining 
or  subjacent  valleys  and  meadow  lands. 

Prognosis.— Either  form  of  dysentery  may  be  fatal;  but  the 
endemic  and  asthenic  type  is  much  the  more  dangerous.  The 
other,  with  good  early  treatment,  is  generally  quite  manageable. 
When  allowed  to  become  chronic  and  ulcerative,  the  doubtfulness 
of  recovery  is  much  greater.  Bilious  dysentery,  that  is,  the  form 
in  which  disorder  of  the  liver  is  a  prominent  feature,  the  dis- 
charges presenting  an  excess  of  more  or  less  altered,  irritating 
bile,  is  more  intractable  than  ordinary  simple  dysentery.  Scor- 
hutic  dysentery  (such  as  was  seen  during  the  Crimean  war,  and  in 
the  Chickahominy  region  of  Virginia  during  the  civil  war  in  this 
country)  is  frequently  fatal. 

Treatment.  Simple  acute  form. — isTow  and  then  we  may  find  a 
robust  patient  who  will  require  to  be  bled  during  the  first,  active 
stage  of  dysentery.  Much  more  often,  leeches  over  the  abdomen, 
where  the  tenderness  is  greatest,  will  be  suitable.  After  these, 
warm  poultices,  of  flaxseed  meal,  mush,  etc.,  may  be  put  on. 
Later,  in  obstinate  cases,  a  large  blister  in  the  same  region. 

At  the  very  start,  the  old  practice  of  beginning  with  a  dose  of 
castor  oil,  with  ten  or  fifteen  drops  of  laudanum,  will  do  very  well. 
If  left  for  a  day  or  two,  it  had,  as  a  rule,  better  be  omitted. 

Then  the  first  prescription,  in  a  mild  or  moderate  case,  may  be 
of  blue  mass  with  ipecacuanha.  After  one  or  two  days  (sooner  in 
an  urgent  case),  camphor  may  be  added,  in  pill.  ISText,  we  may 
substitute,  for  the  blue  pill,  opium;  afterwards,  omit  the  ipecac, 
con  tinning  the  opium  and  camphor,  pi'orenaia.  Some  practitioners 
(Curci')  assert  that  chloral  does  more  good  in  dysentery  than 
opium.  If  the  disorder  be  still  not  checked,  we  must  resort  to 
acetate  of  lead,  with  opium,  or  in  solution  with  acetate  of  mor- 
phia [F.  Ill,  112,  113,  114]. 

Perfect  rest  is  indispensable  to  prompt  recovery  from  dysen- 
tery ;  there  is  no  disease  in  which  this  is  more  important. 

The  diet  must  be  bland  ;  as  rice-water,  arrowroot,  or  other  fari- 
nacea ;  chicken-water,  or  beef-tea  in  the  feeblest  cases.  When 
thirst  is  intense,  iced  rice-water,  or  beune-leaf  tea,  or  infusion  of 
slippery-elm  bark,  may  be  used  as  a  drink  ;  or,  during  the  active 
stage,  ice  in  substance  may  be  taken  slowly. 

Encmata  are  very  important  in  dysentery.  First,  of  flaxseed- 
tea  as  a  demulcent  (two  or  four  ounces  at  once) ;  the  same  with 
laudanum  ;  or  laudanum  with  starch  [F.  115] .  In  decidedly 
sthenic,  inflammatory  cases,  injection  into  the  bowel  of  ice-water 
or  finely  powdered  ice  ^  may  be  resorted  to  ;  taking  care  that  the 

1  Practitioner,  October,  1879. 

2  Bodo  Wenzel ;  Berliner  Klin.  Wochenschrift,  Dec.  1, 1873. 


296        DISEASES  OF  ORGANS  OF   DIGESTION. 

effect  be  kept  short  of  chilling  the  patient.  In  chronic  cases,  or 
obstinate  acute  ones,  acetate  of  lead  may  be  given  by  enema, 
with  laudanum  in  mucilage.  So  may  sulphate  of  zinc  and  nitrate 
of  silver.  Mseder  has  used  with  advantage  enemata  of  alum^  four 
teaspoonfuls  to  a  pint  of  water.  I  have  seen  some  remarkable 
cures  of  chronic  dysentery  by  the  use  of  an  enema  containing 
ten  grains  of  sulphate  of  zinc,  forty  drops  of  laudanum,  and  four 
ounces  of  flaxseed  tea.  Such  an  injection  may  be  painful  at  the 
time,  and  would  be  too  irritating,  except  in  an  ulcerative  case  of 
considerable  standing ;  for  which  it  should  be  reserved.  Solution 
of  tannic  acid,  in  water  or  in  glycerin,  will  be  worthy  of  trial  for 
a  similar  purpose.  Dr.  Morse, ^  of  San  Francisco,  reports  success 
in  chronic  dysentery  with  injections  of  a  solution  of  Labarraque's 
chlorinated  soda  (one  part  to  twenty  of  water),  two  or  three  pints 
at  a  time. 

Asthenic,  endemic  form. — In  this  there  will  be  need  of  the 
earlier  use  of  opium,  and  often  of  quinine  and  stimulants.  ISTo 
leeching,  or  little,  is  likely  to  be  well  borne,  and  ipecac  may  be 
prohibited  by  the  occurrence  of  vomiting.  "When  it  can  be  taken 
in  small  doses  (not  more  than  J  a  grain  every  3  hours),  I  believe 
it  to  be  a  valuable  remedy.  "When  malarial  influence  is  obvious, 
and  most  of  all  in  the  intermittent  form,  quinia  or  cinchouia  will 
be  the  remedy,  to  which  others  are  adjuvants  [F.  117].  Hope''s 
mixture  will  be  more  likely  to  do  good  in  this,  the  adynamic,  than 
in  the  simple  acute  form.  (K. — Acid,  nitric,  f  5j ;  tinct.  opii, 
gtt.  xl ;  aquse  camphorse,  foviij  ;  dose,  a  tablespoonful. )  In 
India,  the  pods  of  the  mangosteen  {Garcinia  mangostana)  have 
been  found  to  furnish  an  extract  serviceable  in  dysentery. 

Bilious  Dysentery. — As  a  distinctive  variety,  this  is  not  uncom- 
mon, and,  if  it  last  over  ten  days,  it  may  be  very  hard  to  cure. 
Ordinary  anti-dysenteric  medication  will  not  be  inappropriate  to 
it,  but  may  disappoint  much  more  than  it  is  apt  to  in  simple  acute 
cases.  Without  having  a  very  satisfactory  recollection  of  the 
results  of  treatment  of  such  cases  in  my  own  experience,  I  should 
trust  most  to  the  withholding  of  mercurials  in  the  first  stage,  the 
gradual  introduction  of  one  of  them  in  the  second  week,  the  appli- 
cation of  a  blister  at  the  same  period  over  the  liver,  and,  besides 
opium,  etc.,  as  required  for  a  stringent  eflect,  the  administration 
of  chloride  of  ammonium,  or  nitro-muriatic  acid.  Of  course  the 
chemical  incompatibility  of  this  acid  with  lead  must  be  remem- 
bered ;  but  this  will  not  interfere  with  saturnine  injections  while 
using  the  acid  by  the  mouth. 

Some  physicians  treat  dysentery,  with  asserted  advantage,  by 
the  internal  administration  of  small  doses  of  sulphate  of  magne- 
sium or  sulphate  of  sodium.  Dr.  L.  D.  Harlow  uses  the  follow- 
ing :  Sulphate  of  sodium,  1  drachm  ;  laudanum,  40  drops  ;  cinna- 
mon-water, 4  fluidounces  ;  mix,  and  give  J  a  fluidounce  every 
three  hours.  This  mode  of  treatment  must,  I  think,  be  best  suited 
to  the  early  stage  of  rather  sthenic  cases. 

If  abscess  of  the  liver  occur  as  a  complication  of  dysentery,  it 
may  require  surgical  treatment.    (See  Hepatitis^  later  in  this  book.) 

1  California  Medical  Gazette,  Sept.,  1868. 


HEMORRHOIDS,  297 

Scorbutic  dysentery  may  require  the  use  of  opiates  and  astrin- 
gents, as  in  the  other  forms  ;  but  anti-morhutic  diet  is  apt  to  be 
the  most  important  portion  of  its  treatment. 

HEMOBRHOIDS. 

Definition. — Piles  ;  tumors  at  the  verge  of  the  anus  or  within 
the  rectum. 

Varieties. — External  and  internal ;  varicose  and  fibrous  ;  dry 
and  bleeding. 

Symptoms. — At  first,  weight  and  fulness  in  the  rectum  ;  sore- 
ness about  the  anus  ;  pain,  increased  upon  having  a  stool.  The 
pain  may  extend  up  the  loins,  and  down  tlie  limbs  even  to  the  feet. 
As  intiammation  increases,  throbbing  and  aching  may  become 
almost  constant.  Swelling,  and  then  the  formation  of  one  or  more 
distinct  tumors,  occur.  If  without  the  anus,  there  may  be  every 
variety  of  pain  fulness,  aggravated  at  certain  times.  If  internal, 
tlie  prolapsus  of  the  tumor  during  defecation,  and  its  constriction 
or  strangulation  by  the  sphincter  ani,  cause  great  suffering  ;  often 
the  tumor  requires  to  be  put  back  by  the  hands.  Occasionally 
it  cannot  be  returned,  but  undergoes  mortification,  and  sloughs 
a  way.  Bleeding  occurs  from  internal  hemorrhoids.  The  amount 
may  vary  from  a  teaspoonful  to  a  pint  or  more  in  a  day.  Cases 
are  recorded  by  good  authorities  in  which  several  pounds  of  blood 
have  been  lost  in  a  single  night.  Commonly  it  is  much  less ;  but 
may  be  enough  to  l>lanch  and  reduce  the  patient  to  the  extreme 
of  anjemia  and  debility. 

Anatomy. — Inspection  shows  external  piles  to  be  globate, 
hroad-])ased  tumors  at  the  verge  of  the  anus,  covered  by  thin 
integument ;  livid  in  color  when  fresh,  losing  that  hue  when  old  ; 
tense  and  elastic  to  the  touch,  and  very  tender,  at  least  during 
inflammation. 

The  old  idea  that  every  hemorrhoid  is  a  dilated  vein  has  been 
corrected  by  observation.  Piles  consist  of  distended  skin  and 
connective  tissue,  with  contained  extravasation  of  blood,  and 
deposit  and  organization  of  lymph,  from  local  congestion. 

Internal  hemorrhoids  are  descril^ed  as  chiefly  of  three  varieties : 
1st.  Solid,  round  or  pear-shaped,  attached  by  a  peduncle,  smooth, 
and  dull  in  color,  composed  of  mucous  membrane,  connective  tis- 
sue, and  thickened  veins.  These  bleed  very  little,  if  any.  2d. 
Broad-based,  bright  red,  spongy  tumors,  villous  on  the  surface, 
and  bleeding  readily  arterial  blood ;  consisting  of  loose  folds  of 
mucous  membrane,  with  hypertrophied  connective  tissue  and 
enlarged  capillary,  small  arterial  and  venous  vessels.  3d.  Florid, 
very  vascular  excrescences  upon  the  mucous  membrane,  not  of 
lai'ge  size,  but  bleeding  sometimes  copiously. 

Complications  and  Sequelae. — These  are,  especially,  ulceration, 
abscess,  fistula,  fissure  of  the  anus,  prolapsus  ani,  and  sympa- 
thetic irritation  of  the  urethra,  bladder,  prostate,  or  testicles  in 
the  male,  or  of  the  uterus  and  vagina  in  the  female.  Slougking 
of  a  strangulated  hemorrhoidal  tumor  is  considered  by  some  to 
endanger  life  ;  but  my  own  observation  of  its  occurrence  would 
lead  me  to  depreciate  this  danger.  Certainly  good  natural  cures 
thus  occur. 


298        DISEASES    OF    ORGANS   OF    DIGESTION. 

Moderate  bleeding  from  inflamed  hemorrhoids  gives  temporary 
relief.  When  habitual  and  not  excessive,  its  sudden  arrest  may 
possibly  j)romote  some  internal  congestion — as  apoplexy. 

Diagnosis. — Hemorrhoids  may  be  mistaken  for  venereal  excres- 
cences, or  polypi  of  the  rectum,  or  for  prolapsus  ani.  The  first 
are  harder,  more  abru^jt  in  their  elevation  and  margins,  and  of  a 
quite  difterent  history  ;  in  addition  to  which  other  marks  of  the 
syphilitic  constitution  exist.  Polypi  are  of  slower  growth,  and 
unaccompanied  by  inflammation,  or,  as  a  rule,  by  hemorrhage, 
and  their  surface  is  smoother  than  that  of  piles.  Prolapsus  ought 
to  be  easily  made  out,  by  examination  discovering  the  structure 
of  the  everted  mucous  membrane. 

The  source  of  bleeding  from  the  rectum  may  sometimes  be  in 
doubt,  as  to  whether  it  be  hemorrhoidal  or  not.  True  hemorrhage 
from  the  bowels,  other  than  from  piles,  is  the  result  commonly  of 
serious  and  obvious  disease  ;  as  typhoid  fever,  yellow  fever,  etc. 
Such  flow  of  blood  is  itself  painless,  and  the  blood  is  dark,  clotted, 
and  variously  mixed  with  fecal  matter  when  passed,  and  the 
symptoms  of  piles  are  absent. 

Causation. — Hereditary  predisposition  sometimes  exists.  Hem- 
orrhoids are  uncommon  in  either  sex  before  puberty ;  in  females 
they  are  most  frequent  at  the  time  of  the  cessation  of  menstrua- 
tion. "Warm  and  damp  climates  promote  them,  as  in  the  East 
and  West  Indies,  etc.  The  plethoric  constitution  is  the  most 
liable  to  them,  especially  with  sedentary  habits.  Pregnancy  is 
attended  by  them  not  unfrequently.  Other  causes  are,  long  stand- 
ing, or  sitting  upon  hard  seats ;  excessive  venery  or  self-abuse  ; 
over-stimulating  diet ;  misuse  of  purgatives,  especially  aloes ; 
ascarides,  diarrhoea,  dysentery,  stone  in  the  bladder.  Constipa- 
tion of  the  bowels  always  predisposes  to  hemorrhoids. 

Treatment. — This  must  be  both  general  and  local;  the  former 
depending  upon  the  constitutional  condition,  and  the  cause  of  the 
affection.  The  bowels  must  be  regulated;  neither  over-purged  nor 
allowed  to  be  costive  ;  a  soluble  state  is  the  most  desirable.  The 
bleeding  of  piles  must  be  but  cautiously  interfered  with,  if  it  has  been 
habitual,  or  if  there  be  a  tendency  to  apoplexy,  gout,  or  insanity. 

The  diet  must  be  made  to  consist  of  digestible  and  unirritating 
food.  Long  standing  and  sitting,  or  rough  riding,  must  be 
avoided  ;  although  active  exercise  in  the  open  air  may  be  very 
advantageous. 

External  piles  may  often  be  averted  in  the  forming  stage  by 
attention  to  the  bowels,  along  with  the  frequent  application  of 
the  simplest  unguents  to  the  irritated  and  swollen  part.  Lard, 
tallow,  cold  cream,  simple  cerate,  benzoated  vaseline,  or  sperma- 
ceti ointment,  will  answer  very  well ;  but  the  grease  should  be 
applied  several  times  daily,  and  especially  after  a  stool,  so  as  to 
keep  the  part  constantly  soothed  by  it  [F.  118,  119,  120,  121]. 
Dr.  H.  C.  Wood^  recommends  enemata  containing  chlorate  of 
potassium  and  laudanum. 

The  laxatives  most  approved  for  hemorrhoidal  cases  are  rhu- 
barb, sulphur,  and  senna.     The  confection  of  senna  is  a  very  good 

1  Phila.  Med.  Times,  Dec.  6, 1879. 


HEMORRHOIDS.  299 

preparation  for  such  use.  Map;nosia  is  irritant  to  piles  ;  and  so 
are,  thougli  in  less  degree,  the  fealine  catharti(;s.  Aloes  is  stimu- 
lant to  the  sensibility  of  the  lower  bowel ;  yet  some  practitioners 
(as  Fordyce  Barker)  lind  it.  in  moderate  or  small  doses,  especially 
with  hyoscyamus,  a  useful  alterative  in  hemorrhoids.  Dr.  D. 
Young  thinks  highly  of  ghjcerin  for  a  similar  eflect.  Enemata 
are  objectionable  merely  because  of  the  mechanical  pressure  of 
the  instrument.  In  internal  hemorrhoids  they  are  often  decidedly 
serviceable.  When  piles  arc  inflamed,  washing  with  cold  water, 
or  a  cool  sitz-bath,  may  relieve.  '  Some  patients  prefer  warm 
water  or  soapsuds  under  the  same  circumstances. 

"When  bleeding  is  so  considerable  as  to  need  to  be  checked,  cold 
water  injections,  or  liot  water,  solution  of  alum,  or  tincture  of  iron, 
may  be  employed.  A  piece  of  alum  made  into  a  smooth  supposi- 
tory will  sometimes  do  well.  In  really  threatening  hemorrhage 
the  patient  must  lie  still  in  bed. 

On  the  other  hand,  inflamed  non-bleeding  piles  may  require 
local  depletion  by  leeches,  or,  as  many  prefer,  cupping  over  the 
sacrum. 

Prolapsed  internal  hemorrhoids  often  have  to  be  replaced  by 
the  hand.     Oiling  will  of  course  facilitate  such  reduction. 

Astringent  and  sedative  ointments,  as  of  galls,  tannin,  carbon- 
ate of  lead,  creasote,  or  iodoform,  with  regimen  and  laxatives, 
may  cure  piles  even  of  considerable  standing.  [F.  118, 119, 120.] 
But  old  and  obstinate  cases  demand  removal  by  operation. 

External  hemorrhoids  may  be  excised^  with  curved  scissors  or 
a  probe-pointed  straight  bistoury  ;  taking  off  no  more  integument 
than  what  covers  the  tumors.  Fain  during  the  operation  maybe 
prevented  (Coote)  by  the  ether  spray.  Allingham^  employs  a 
clamp.  Good  authority,  also,  pronounces  touching  carefully  with 
nitric  acid  to  be  safe  and  successful. 

Internal  hemorrhoids  ought,  when  operated  upon,  to  be  re- 
moved always  by  ligature.  Excision  is  dangerous,  and  has  several 
times  been  fatal  by  hemorrhage.  Some  prefer  cauterization  with, 
nitric  acid.  In  ligating  hemorrhoids,  it  is  best  to  apply  a  double 
ligature  around  the  base  of  each  tumor.  Silk  or  hemp  will  answer ; 
Bushe's  needle-receiver  is  a  good  instrument  for  the  application. 
Colles,  of  Dublin,  1874,^  introduced  the  treatment  of  hemor- 
rhoidal tumors  by  injection  with  tincture  of  chloride  of  iron.  In  this 
country,  first  in  the  West,^  it  has  become  common  to  inject  carbolic 
acid;  with  reported  success  in  many  cases.  Dr.  Blackwood,* 
of  Philadelphia,  thus  describes  the  operation  :  "I  use  crystallized 
carbolic  acid,  with  enough  glycerin  (a  few  drops  only)  to  render 
it  fluid.  Empty  the  bowel  thoroughly  the  day  before,  and  the 
rectum  by  enema  an  hour  before  operating.  Do  not  inject 
during  acute  inflammation — a  fit  of  the  piles.  Put  the  patient 
in  bed.  Anoint  the  mass  of  tumors,  after  their  extrusion,  with 
fresh  olive  oil  or  cosmoline,  to  prevent  accidental  caustic  action 
on  the  adjoining  parts,  especially  in  females.     Use  a  good  glass 

1  Diseases  of  the  rectum,  etc.,  2d  edition,  1873. 

2  Dublin  Journal  of  Med.  Science,  June,  1874. 
sPooley,  Toledo  Med.  and  Surgical  Journal,  Nov.,  1877. 
<N.  Y.  Med.  Kecord,  Oct.  2,  1880,  p.  386. 


300        DISEASES   OF   ORGANS   OF   DIGESTION. 

hypodermic  syringe,  with  a  tight  piston,  which  moves  easily,  and 
a  small,  well-polished,  and  sharp  needle.  See  that  the  needle  is 
pervious  to  the  acid  (not  to  water)  before  commencing.  Select 
the  largest  pile,  and  push  the  point  of  the  needle  to  the  centre 
only,  and  not  beyond  the  tumor,  then  slowly  inject  from  three  to 
six  drops.  If  the  pile  is  as  large  as  a  small  walnut,  I  put  in 
three  drops  at  one  point,  partially  withdraw  the  needle,  and 
deposit  three  drops  at  another  point,  and  sometimes  at  a  third. 
Inject  only  one  pile  at  a  time,  unless  they  are  small,  when 
two  may  be  attacked  at  one  operation.  Keep  the  needle  in  the 
pile  for  a  few  seconds  before  withdrawing  it  fully.  The  object  is 
to  permit  the  mass  to  harden  before  taking  the  needle  out.  If  the 
pile  bleeds,  touch  it  with  a  piece  of  ice  or  the  strong  carbolic  acid. 
Ko  bleeding  resulting,  thoroughly  anoint  the  tumors  as  at  first, 
and  return  them  within  the  sphincter.  A  suppository  may  also 
be  introduced,  but  I  prefer  morphia  hypodermically.  Keep  the 
patient  in  bed,  and  in  two  or  three  days  inject  another  if  it  exist, 
and  repeat  at  this  interval  until  all  are  done.  The  process 
mummifies  and  shrivels  the  hemorrhoids,  and  does  not  cure  by 
inflammation,  ll^ow  and  then  the  whole  or  a  part  of  the  pile  may 
slough,  but  the  process  is  limited." 

FISSURE  OF  THE  AUniS. 

This  is  a  very  painful  and  not  uncommon  affection,  especially 
in  middle  life  ;  perhaps  most  frequent  in  females.  IsTeglected  con- 
stipation and  hemorrhoids,  with  relaxation  of  constitution  and 
sedentary  habits,  are  its  principal  causes. 

Its  symptoms  are,  at  first,  soreness  or  smarting  at  one  point  of 
the  anus  when  at  stool.  This  becomes  afterwards  very  severe, 
with  intense  pain,burning,  aching,  and  throbbing,  and  violent  spas- 
modic constriction  of  the  sphincter  ani,lastingsometimesfor  hours. 

Examination  displays  a  lesion  mostly  of  the  mucous  membrane 
only  ;  though  occasionally  reaching  even  to  the  muscular  fibres 
of  the  sphincter.  In  the  beginning  only  a  crack,  it  becomes  at 
last  an  extended  ulcer,  and  may  exist  on  each  side  of  the  anus. 

The  stools  are  streaked  with  pus  or  blood,  and  often  reduced  in 
size  by  the  spasm  of  the  sphincter  ;  suggesting  stricture  of  the 
rectum  ;  for  which  this  complaint  has  now  and  then  been  mis- 
taken. The  suffering  of  the  patient  in  bad  cases  is  extreme  ;  pain 
being  produced  not  only  by  defecation,  but  also  by  coughing, 
sneezing,  stimulating  food,  or  even  by  the  sitting  posture. 

Treatment.^ — Most  cases,  even  of  long  standing,  may  he  cured 
without  an  operation.  The  fissure  may  be  managed  as  an  irrita- 
ble ulcer,  by  the  constant  application  of  soothing  unguents— as 
spermaceti  or  oxide  of  zinc  ointment,  lead  cerate,  unguentum 
belladonnse,  or  lime-water  with  oiled  silk  dressing.  The  latter 
will  be  convenient  only  in  the  recumbent  posture.  Experience 
leads  me  to  have  especial  confidence  in  collodion,  to  which  one- 
fiftieth  of  glycerin  has  been  added  to  lessen  its  constricting  effect. 
This  may  be  painted  upon  the  part  with  a  camel's-hair  pencil,  as 
in  fissure  of  the  nipple ;  it  makes  an  excellent  artificial  cuticle. 
Glycerite  of  tannin  [F.  205]  and  compound  tincture  of  benzoin, 
may  also  be  useful.     Iodoform  suppositories  arc  recommended  by 


CONGESTION    OF    THE    LIVER.  301 

Dr.  J.  C.  Peters.'  Tarnicr  dusts  the  part  with  iodoform  powder. 
Crrquy  has  employed  a  dressing  of  chorpie  soaked  in  hydrate  of 
chloral  witli  advantage. '■' 

Ohstinate  cases  may  be  treated  with  nitrate  of  silver  or  sulphate 
of  copjier,  applied  every  day  or  two,  lightly,  to  the  surface. 
Where  suffering  is  great,  suppositories  of  opium  and  cocoa  butter, 
or  of  belladonna,  may  be  introduced  after  defecation.  Washing 
with  soap  and  water,  twice  daily,  will  be  serviceable. 

Should  all  such  measures  fail,  Boyer's  operation,  as  modified 
by  Copeland  and  Brodie,  should  be  resorted  to.  It  is,  incision 
through  the  ulcer,  with  a  bistoury,  either  from  within  outwards, 
or  from  without  inwards.  It  is  only  necessary  to  cut  through 
the  mucous  membrane,  not  through  the  sphincter.  Mild  dressings 
must  follow  the  incision;  which  will  usually  produce  rapid  recovery. 

Dr.  W.  II.  Van  Buren's  operation  consists  in  the  forced  dilata- 
tion of  the  sphincter  ani,  by  the  two  thumbs  of  the  operator ;  so 
as  to  overcome  the  spasmodic  contraction. 

PEOLAPSUS  ANI. 

Partial  descent  of  the  rectum  beyond  the  anus  is  not  rare  in 
adults,  but  is  more  common  in  children.  Relaxation  of  the 
mucous  membrane,  or  weakening  of  the  anal  muscles,  may  induce 
it ;  straining  at  stool  is  its  usual  immediate  cause.  Tropical 
countries  aflbrd  its  most  numerous  examples. 

Treatment. — The  protruded  bowel  must  be  replaced.  Com- 
monly, gentle  pressure,  with  lard  or  oil,  and  tact,  will  succeed  at 
once.  If  not,  leeches  and  cooling  applications  must  be  applied 
to  reduce  congestion  and  swelling.  Sometimes  anaesthesia  will 
be  a  needful  aid  ;  but  not  often. 

Having  effected  the  replacement,  a  pad  and  T  bandage  will 
maintain  it  for  the  time.  The  bowels  must  then  be  carefully  reg- 
ulated. For  the  rest,  lyreventive  care  is  the  main  thing.  Children 
affected  with  prolapsus  must  not  be  allowed  to  strain.  The  chair 
or  other  seat  used  by  them  ought  to  be  high,  so  as  not  to  flex  the 
thighs  much  upon  the  body.  The  more  nearly  erect  the  posture, 
the  less  force  in  bearing  down. 

Old  prolapsus  in  the  adult  may  not  be  curable  without  opera- 
tion ;  although  the  air-dilated  gum-elastic  pessary  will  sometimes 
give  relief.  I  refer  for  the  operation  to  works  on  surgery.^  In 
cases  of  great  relaxation,  strychnia  (Kdlaton)  by  the  mouth  or 
hypodermically  (L.  Weber,  JS".  Y.,  1868)  may  be  cautiously  ad- 
ministered. Vidal  has  cured  three  cases  by  repeated  hypodermic 
injections  of  ergotin  (extract  of  ergot). 

AFFECTIOE^S  OP   THE  LIVER. 

ACUTE  CONGESTIOlSr. 

This,  with  deficient  secretion  of  the  bile,  is  very  common,  as 
the  result  of  exposure  to  cold  and  wet  in  warm  seasons  or  cli- 
mates, of  the   chill  of  intermittent,  or  of  excess  in  diet.     Its 

1  Phila.  Med.  Times,  Nov.  8, 1879.    See  also,  Tarnier,  Union  Medicale,  Dec.  27,  1877. 
2Bull.  Gen.  de  Therap.,  Sept.  30,  1875. 
8  See  Ashton  on  the  Rectum,  p.  157. 

26 


302  DISEASES    OF    THE    LIVER. 

symptoms  are,  a  sense  of  weight  and  slight  or  moderate  pain 
in  the  right  hypochondriac  region  and  under  the  right  shoulder- 
blade,  constipation  and  lead-colored  stools,  nausea,  a  furred 
tongue,  bitter  taste  in  the  mouth,  a  yellowish  skin  and  con- 
junctiva, and  headache  or  dizziness. 

Treatment. — Two  or  three  grains  of  blue  mass  ^  at  bedtime, 
one,  two,  or  three  nights  (two  grains  only  if  repeated).  When 
decided  constipation  exists,  one  purging  dose  in  the  morning,  of 
sulphate  or  citrate  of  magnesium,  or  of  magnesia.  Then  ten  or 
fifteen  grains  of  bicarbonate  of  sodium  twice  daily  with  light  diet. 

Dr.  W.  Stewart  -  particularly  recommends  chloride  of  mnmonium 
for  this  affection,  after  diaphoretics  (as  acetate  of  potassium  or 
ammonium)  if  the  skin  be  hot  and  dry.  I  have  no  doubt  of  its 
value.  Extract  of  taraxacum  (dose,  ten  to  twenty  grains)  has 
long  been  a  favorite  medicine  with  many  practitioners. 

Having  no  desire  to  ignore  or  depreciate  the  suggestiveness  of 
experiments  upon  animals,  the  following  may  be  given  as  a  sum- 
mary of  the  most  important  inferences  derived  from  Rutherford's 
vivisections  of  dogs : 

Powerful  stimulants  to  the  secretion  of  bile  :  podophyllum,  ben- 
zoates  of  sodium  and  ammonium,  benzoic  acid  (less),  salicylate 
of  sodium,  sauguinarin,  phosphates  of  sodium  and  ammonium, 
ipecacuanha,  corrosive  sublimate,  aloes,  colocynth,  colchicum. 

Moderate  hepatic  stimulants :  leptandrin,  jalap,  dilute  nitro- 
muriatic  acid,  rhubarb. 

Feeble  hepatic  stimulants :  scammony,  Kochelle  salts,  croton 
oil,  taraxacum,  jaborandi,  chloride  of  sodium ;  bicarbonates  of 
sodium  and  j)otassium  only  when  given  in  large  doses. 

CHEOmC  CONGESTION  OF  THE  LIVER. 

A  number  of  attacks  of  temporary  hepatic  congestion,  or  of 
hepatitis,  or  prolonged  dyspepsia,  or  intermittent  or  remittent 
fever,  may  induce  a  chronic  hypersemia  of  the  liver,  with  variable 
disturbance  of  function.  Pain  in  the  right  side  and  shoulder, 
with  sallowness  of  complexion,  constipation,  and  lowness  of 
spirits,  are  the  principal  symptoms. 

Treatment. — Supposing  blue  mass  to  have  been  temporarily  and 
sufficiently  used,  as  the  leading  remedy,  nitro-muriatic  acid  may 
then  be  given,  3  or  4  drops  twice  or  thrice  daily,  for  two  or  three 

1  It  has  been  remarked  already,  that  Prof.  J.  H.  Bennett's  experiments,  and  those  of 
others,  appearing  to  show  that  mercurials,  in  healthy  animals,  rather  diminish  than 
increase  the  flow  of  bile  from  the  liver,  do  not  in  the  slightest  degree  affect  the  value 
of  the  evidence  which  has  established  the  usefulness  of  blue  pill  and  calomel  in  acute 
or  subacute  hepatic  disorders.  It  is  only  the  explanation  of  their  remedial  action  that 
can  be  thus  brought  into  question ;  not  the  facts  which  prove  it.  Some  experiments, 
moreover,  have  differed  in  their  results  from  Bennett's ;  and  we  cannot  argue  with 
certainty  from  the  case  of  dogs  in  the  state  of  health  to  that  of  men  in  a  condition  of 
illness.  See  remarks  of  Dr.  Da  Costa  upon  a  case  in  which  increase  of  bile  after  calo- 
mel appeared  to  be  proved.     Proceedings  of  Pathol.  Society  of  Philadelphia,  July,  1869. 

Eohrig,  with  an  improved  method  of  experimentation,  approved  by  Strieker,  showed 
(1872-3)  that,  in  dogs,  the  secretion  of  bile  is  augmented  by  any  cause  of  determination 
of  blood  to  the  liver.  Several  kinds  of  cathartics  had  this  eifect ;  salines,  rhubarb,  cas- 
tor oil,  etc.  Rutherford's  investigations  also  are  very  interesting;  but  more  valuable 
still  is  Murchison's  experience  (Croouian  Lectures,  1874)  that  "the  clinical  proofs  of 
the  efficacy  of  mercury  as  a  cholagogue  are  overwhelming."  Christison  has  given 
equally  strong  testimony. 

2  British  Med.  Journal,  September,  1878. 


HEPATITIS.  303 

weeks  successively.  Or  it  may  be  used  in  a  bath  (f5vj-viij  in 
each  gallon  of  watc^-).  Chloride  of  anunoniuni,  10  grains,  or 
taraxacum,  10  or  '20  grains  of  the  extract  twice  daily,  or  a  wine- 
glassful  as  often  of  the  dt  coction  of  the  root,  or  the  fresh  leaves 
in  spring  or  summer,  eaten  as  greens,  may  follow.  Leptandrin 
(dose,  gr.  j-iij)  is  believed  to  be  mildly  cholagogue  and  safe.  So 
is  the  resin  of  podophyllum,  in  very  small  doses.  Ordinary  lax- 
atives, as  rhubarb,  etc.,  may  be  used  to  regulate  the  bowels. 
Care  of  the  skin,  by  bathing,  proper  clothing,  and,  if  chilly,  fric- 
tion with  hair  gloves  or  a  rough  towel  (salt-bathing  will  be  very 
good)  is  important.  Exei-cise  in  the  open  air,  not  violent,  should 
be  had  every  day.  Change  of  air,  mineral  waters,  or  sea-bathing, 
may  be  advised. 

HEPATITIS. 

The  most  common  form  of  inflammation  affecting  the  liver  is 
what  some  writers  call  "  gastro-hepatic  catarrh  ;  "  considered  on 
a  previous  page.  (See  Gmtritis.)  There  is  reason  to  believe  the 
duodenum,  stomach,  gall-duct,  and  liver,  to  be  all,  in  variable 
degree,  involved  in  such  attacks. 

Hepatitis  may  also  be  traumatic.  Whether  so  or  idiopathic, 
either  the  parenchymatous  tissue,  Glisson's  capsule,  the  biliary 
ducts,  or  the  portal  vein,  or  all  together,  may  be  the  seat  of 
inflammation. 

Some  of  the  symptoms  are  nearly  the  same  in  all  cases,  and  are 
in  part  the  same  as  in  acute  congestion  of  the  liver  ;  but  the  pain 
in  the  side  is  greater,  with  some  tenderness  on  pressure  ;  there 
is  fever,  often  vomiting,  and  sometimes  diarrhoea. 

In  inflammation  of  the  capsule  (perihepatitis)  the  tenderness 
on  pressure,  movement,  or  deep  inspiration,  is  considerable  ;  the 
fever,  slight  or  absent,  and  there  is  no  jaundice.  This  may  some- 
times be  confounded  with  drnphrayviatic  jjleurisij ;  but  there  is,  in 
the  latter  complaint,  more  severe  pain,  with  cough,  dyspnoea,  and 
hiccough. 

Inflammation  of  the  portal  vein  may  proceed  to  suppuration. 
Then  the  symptoms  are  scarcely  distinguishable  from  those  of 
hepatitis  with  abscess,  to  which  attention  will  be  given  presently. 

When  inflammation  is  chiefly  confined  to  the  gall-bladder  and 
ducts,  the  points  of  diagnosis  are  the  comparative  absence  of 
fever  and  the  considerable  degree  of  jaundice. 

Abscess  of  the  Liver. — Although  much  most  common  in  trop- 
ical climates,  this  maybe  met  with  anywhere.  Besides  the  usual 
symptoms  of  hepatitis,  when  pus  is  forming  we  find  rigors  re- 
curring sometimes  almost  as  regularly  as  in  intermittent,  a  very 
rapid  pulse,  prostration,  copious  perspirations,  and  loss  of  flesh. 
In  a  considerable  number  of  cases,  however  (13  per  cent.,  accord- 
ing to  Louis),  the  disorder  is  latent,  being  made  known  only  by 
the  consequences  of  suppuration. 

The  greatest  danger  attends  the  escape  of  pus  from  the  abscess. 
This  occurs  spontaneously  either  through  the  diaphragm  by  the 
lungs,  into  the  stomach,  or  intestinal  canal,  into  the  peritoneal 
cavity,  or,  in  a  minority  of  cases,  through  the  skin.  Any  of 
these  may  be  followed  by  recovery,  except  the  escape  into  the 


304  DISEASES     OF    THE    LIVER, 

cavity  of  the  peritoneum.  In  this  instance  death  is  almost 
certain. 

The  causes  of  abscess  of  the  liver,  besides  the  predisposition 
belonging  to  hot  climates,  are  :  1,  Blows  or  wounds ;  2.  Inliam- 
mation  of  the  portal  vein,  with  deposit  of  pus,  or  transfer  from 
thrombosis  of  some  other  vein,  as  the  hemorrhoidal ;  3,  Dysenteric 
ulceration ;  4,  Inflammation  and  suppuration  of  the  gall-bladder 
or  gall-ducts. 

Treatment  of  Acute  Hepatitis. — A  highly  inflammatory  case 
in  a  vigorous  subject  may  be  treated  by  early  venesection.  Other- 
wise, leeches  to  "the  right  hypochondrium  will  be  suitable.  All 
mercurials  should  be  avoided.  Saline  cathartics  are  proper,  with 
rest  in  bed,  low  diet,  and  cooling  drinks,  A  blister  may  follow 
leeches  or  cupping. 

In  the  hepatitis  frequently  occurring,  and  sometimes  fatal,  in 
India,  Dr.  W,  Stewart'  considers  chloride  of  ammonium  almost  a 
"  specific  "  remedy. 

The  most  serious  question  occurs  when  suppuration  is  known 
or  believed  to  have  taken  place.  Can  we  prevent  or  lessen  the 
dangers  of  the  discharge  of  the  abscess  ?  Nature  in  many  cases 
makes  this  secure,  by  adhesion  of  the  liver  to  the  stomach  or 
bowel,  so  as  to  allow  of  the  direct  flow  of  the  pus  into  the  alimen- 
tary canal.  In  other  instances  deep-seated  fluctuation  may  be  felt 
below  the  edge  of  the  ribs.  Possibly  this  might  be  a  dilated  gall- 
bladder^ or  hydatids  of  the  liver.  But  if  sure  that  it  is  an  abscess, 
ought  we  to  open  it  ?  The  most  prudent  answer  is,  not  unless  we 
are  confident  that  only  the  skin  intervenes  between  the  pus  and 
the  exterior.  A  very  judicious  medium  between  this  and  bolder 
practice  has  been  proposed  by  Dr,  Graves  :  to  make  an  incision 
about  four  inches  long  right  over  the  centre  of  the  tumor,  but 
reaching  through  the  muscle  to  within  a  few  lines  of  the  perito- 
neum.  This,  even  when  the  matter  is  deeply  seated,  is  shown  by 
experience  to  favor  and  hasten  essentially  its  escape,  witliout  the 
dangers  of  a  peritoneal  incision,  Dr,  C.  Murchison  approves  of 
making  an  opening  in  all  cases  in  which  there  is  a  visible  fluctu- 
ating tumor. 

It  seems  probable  that  Dieulafoy's  aspirator  will  contribute  to 
the  ease  and  safety  of  the  management  of  such  cases. 

Dr.  Hammond,  several  years  ago,^  asserted  the  observation  that, 
in  some  cases,  cerebral  hypersemia,  depression  of  spirits,  insomnia 
and  gastric  disorder  are  associated  with  hepatic  abscess,  without 
distinctive  local  signs  of  it.  On  aspirating  the  liver,  in  such  in- 
stances, the  withdrawal  of  a  quantity  of  pus  has  been  followed  by 
recovery.  When  no  such  result  has  attended  the  operation,  it  has 
no  ill  effects.  His  punctures  were  made  between  the  eighth  and 
ninth,  or  ninth  and  tenth  ribs,  into  the  right  lobe  of  the  liver. 
J,  M.  Sims,  Tausky,  and  others,  confirm  the  safety,  and  in  some 
instances  the  advantage  of  this  practice. 

On  the  other  hand,  Morehead,  Maclean,^  Lowe,  and  others,  on 
the  basis  of  experience  in  India,  where  hepatic  affections  are 

1  Medical  Press  and  Circular,  Aug.  30,  1871. 

2  St.  Louis  Clinical  Record,  June,  1878. 

8  Eeynolds'  System  of  Medicine,  Amer.  edition,  Vol.  III.,  p.  374, 


JAUNDICE.  305 

freqiiont,  hiivo,  objected  to  all  such  "exploratory"  operations 
upon  the  liver.  Maclean  asserts  that  the  most  favorable  route 
of  discharge  for  an  abscess  of  the  liver  is  through  the  right 
lung,  and  the  least  hopeful  that  through  the  abdominal  walls. 
Whei-e  rupture  or  escape  of  pus  outwardly  occurs  spontane- 
ousl}',  it  appears  to  be  almost  always  (Morehead  and  Maclean) 
just  below  the  ensiform  cartilage. 

J^ater  experience,  however  (Brit.  Med.  Journal,  18R0),  appears 
to  have  led  Maclean  to  favor  puncture  of  large  hepatic  abscesses 
under  (Lister's)  "antiseptic  precauticms."  Dr. Little, of  Shanghai, 
China,  has  concluded  it  best  to  use  aspiration  for  diagnosis,  and 
free  incision  for  treatment.  Rochard,  of  Paris,  also  adopts  this 
view.  When  "  Listerism  "  is  impracticable,  incision  or  puncture 
of  a  large  abscess  may  be  made  with  a  trocar  and  canula,  fol- 
lowed by  the  introduction  of  a  drainage  tube,  through  which 
carbolized  solutions  may  be  injected.' 

After  the  discharge  of  the  abscess,  convalescence  may  be  ex- 
pected; it  is  sometimes  rapid,  but  may  require  a  month  or 
two. 

JAUNDICE. 

Icterus,  or  jaundice,  is  a  morbid  yellowness  of  the  skin,  eye, 
and  other  parts.  It  has  no  uniform  pathology,  causation,  or  con- 
current symptoms ;  but  is  itself  so  marked  an  occurrence  as  to 
deserve  special  study.  Sometimes  it  is  even  epidemic,  as  in  the 
U.  S.  army  in  malarial  districts  during  the  late  war ;  to  the  ex- 
tent of  over  10,000  cases  in  a  single  year. 

Varieties.- — As  to  degree — yellow,  green,  and  black  jaundice.  As 
to  causation,  jaundice  from  suppression  and  from  reabsorption  of 
bile ;  and  icterus  neonatorum,  jaundice  of  young  infants,  of  still 
different  origin. 

Symptoms. — In  ordinary  acute  cases  of  jaundice,  either  sud- 
denly or  after  some  days  of  malaise,  the  whites  of  the  eyes  first 
become  tinged  with  yellow ;  next,  the  roots  of  the  nails,  the 
face,  neck,  trunk,  and  limbs.  The  urine  is  of  a  porter  color, 
stains  linen  yellow,  and  becomes  green  on  the  addition  of  nitric 
acid.  At  the  same  time  the  stools  are  slate  or  lead-colored,  or 
almost  white.  The  mouth  has  a  bitter  taste,  and  the  patient  suf- 
fers with  lowness  of  spirits  and  indisposition  for  exertion.  Icterus 
neonatorum  commonly  begins  to  appear  within  two  or  three  days 
after  birth,  and  seldom  continues  for  much  more  than  a  week. 

Pathology  and  Causation. — Many  aflections  of  the  liver  may 
induce  jaundice,  although  in  some  of  the  most  serious  of  them  it 
may  be  absent.  Most  distinctly  it  is  traceable  in  different  cases 
to  the  non-removal  of  the  biliary  coloring  matter,  as  well  as  of 
cholesterin,  from  the  blood  by  the  liver — other  organs,  especially 
the  skin,  then  receiving  it — or  to  obstruction  preventing  its 
transit,  after  secretion,  tlirough  the  intestinal  canal,  in  which 
case  it  is  reabsorbed  into  the  blood,  and  is  then  tlirown  out  else- 
where. Virchow  recognizes  a  form  of  jaundice  as  "htemato- 
genic,"  that  is,  originating  in  the  blood.     This  is  probably  true, 

1  See  a  paper  by  Dr.  E.  Winslow,  of  Baltimore,  in  Annals  of  Anatomy  and  Surgery, 
June,  1881. 

26*  U 


306  DISEASES    OF    THE    LIVER. 

at  all  events,  of  the  jaundice  of  new-born  infants.  Ponfick  thus 
explains  also  the  sudden  production  of  jaundice  by  powerful 
emotion.  The  common  view,  that  some  cases  of  jaundice  de- 
pend directly  upon  suppression  of  the  removal  of  bile  pigment 
from  the  blood  by  the  liver,  has  had  doubt  cast  upon  it  by  Mur- 
chison^  and  others.  It  is  even  doubtful  whether  biliary  pigment 
really  exists  pi-e-formed  in  the  blood ;  especially  as  extirpation 
of  the  liver  in  animals  is  not  followed  by  jaundice,  and  in  a 
number  of  cases  of  destructive  diseases  of  the  liver  jaundice  is 
absent.  Bence  Jones  asserts'^  that  at  all  times  a  certain  amount 
of  bile  is  transfused  through  the  coats  of  the  gall-bladder  into 
the  blood;  in  health  soon  to  undergo  oxidation,  but  not  so  when 
the  balance  of  blood-change  is  disturbed. 

The  remote  causes  of  jaundice  of  greatest  frequency  are  ma- 
laria, exposure  to  cold  and  damp  in  hot  weather,  pregnancy,  and 
violent  mental  emotion. 

Diagnosis. — In  either  form  of  jaundice  we  have  the  yellow  con- 
junctiva and  skin,  or  serum,  if  a  blister  be  applied,  or  blood 
drawn  ;  in  both  the  stools  are  without  color,  and  the  urine  yellow 
or  yellowish-brown.  But,  as  Harley  first  pointed  out,  in  jaundice 
from  suppression  the  biliary  acids  have  not  been  formed,  and  we 
find  only  the  bile  pigment  in  the  urine,  while  in  jaundice  from  re- 
absorption^  that  fluid  contains  both. 

Harley 's  test  is  as  follows:  "To  a  couple  of  drachms  of  the 
suspected  urine  add  a  small  fragment  of  loaf  sugar,  and  after- 
wards pour  slowly  into  the  test-tube  about  a  drachm  of  strong  sul- 
phuric acid.  This  should  be  done  so  as  not  to  mix  the  two  liquids. 
If  biliary  acids  are  present,  there  will  be  observed  at  the  line  of 
contact  of  the  acid  and  urine,  after  standing  for  a  few  minutes,  a 
deep  purple  hue."     (See  Semeiology^  Part  I.) 

After  a  time,  in  cases  in  which  the  secretory  powers  of  the  liver 
become  impaired,  the  biliary  acids  disappear,  and  then  tyrosin 
and  leucin  are  found  in  the  urine.  To  detect  these,  evaporate 
slowly  an  ounce  of  the  urine  to  the  consistence  of  syrup,  and  put 
it  away  to  crystallize.  Tyrosin  is  known  by  fine  stellate  groups  of 
needles  under  the  microscope.  Leucin,  by  flat  circular  crystal- 
line disks,  soluble  in  water  but  not  in  ether. 

IsTothnageP  has  pointed  out  that  in  intense  jaundice  (icterus 
catarrhalis),  along  with  the  biliary  acids,  renal  tube-casts  appear 
in  the  urine. 

Prognosis, — Acute  jaundice  is  not  very  often  fatal.  In  the 
U.  S.  army,  of  10,929  cases  only  40  died.  When  it  lasts  a  month 
or  two,  however,  as  well  as  when  acute  yellow  atrophy  of  the  liver 
exists,  there  is  always  danger  connected  with  its  organic  cause. 
The  jaundice  of  young  infants  is  of  short  duration,  and  almost 
never  of  serious  consequence. 

Treatment. — When  supposed  to  be  temporary  and  functional, 
the  great  object  must  be  to  restore  the  action  of  the  liver.  As 
observed  already,  the  large  accumulation  of  clinical  experience, 
sustained  by  some,  though  not  by  all,  of  the  physiological  experi- 

1  Clinical  Lectures  on  Diseases  of  ttie  Liver,  etc.,  1868. 

2  St.  George's  Hospital  Reports,  1866. 

3  Deutsches  Archiv  fur  Clin.  Med.,  Oct.,  1873 


ACUTE     YELLOW     ATROPHY.  307 

mcnts  made  by  vivisectors,  compels  the  belief  that  calomel  and 
blue  mass  and  otluT  mercurials  are  diolcK/oyiics.  If  they  be  not  so 
alivdi/.t  in  trials  upon  animals  in  health.,  they  have  proved  so  gener- 
alhj  in  human  beings  in  cases  of  torpor  of  the  liver.  If  obstructirm 
be  the  trouble,  their  action  is  more  doubtful,  necessarily.  But 
even  then  they  may  promote  the  solution  of  a  recent  gall-stone, 
if  they  render  the  bile  more  copious  and  liquid. 

Heberden  long  since  advocated  the  administration  of  ether  as  a 
solvent  of  biliary  calculi.  In  obstructive  jaundice,  the  abundant 
imbibition  of  water  is  reasonably  indicated,  to  tlavor  fluidity  of 
the  secretions.     (See  Bilious  Colic,  p.  282.) 

Moderate  doses  of  calomel  or  blue  pill  may  be  urged,  then, 
generally,  during  the  first  week  or  more  of  treatment.  These  may 
be  aided  l)y  saline  purgatives,  as  sulphate  or  citrate  of  magnesium, 
Eochelle  salts,  or  cream  of  tartar.  After  them,  small  doses  of 
resina  jJodophyUi  may  be  tried,  if  required  by  persistence  of  the 
disease  ;  or,  if  the  bowels  will  not  bear  purging,  chloride  of  am- 
monium or  extract  of  taraxacum.  But  in  a  case  of  some  weeks- 
duration,  slow  to  recover,  nitro-muriatic  acid,  3  to  4  drops  twice 
or  thrice  daily,  will  often  hasten  recovery  very  much.  This 
occurred  under  my  observation  in  a  number  of  cases  of  malarial 
jaundice  from  the  Army  of  the  Potomac  in  1862.  Dr.  H.  Cook, 
of  Bomljay,  has  found  large  doses  of  ipecac  very  beneficial  in 
jaundice. 

ACUTE  YELLOW  ATROPHY. 

This  is  a  rare  but  generally  fatal  affection,  seen  most  frequently 
in  those  who  have  been  intemperate,  or  injured  by  venereal  ex- 
cesses, or  who  have  been  exposed  to  malaria. 

Symptoms. — Beginning  like  ordinary  jaundice,  with  nausea, 
constipation,  and  headache,  the  skin  becomes  intensel}^  yellow 
("black  jaundice  ");  vomiting  comes  on,  the  pulse  is  rapid,  though 
variable,  and  delirium  occurs.  Then,  with  fever,  and  often  pain 
in  the  side,  the  stomach  and  head  are  more  and  more  disturbed. 
Yomiting  of  altered  blood  takes  place  ;  not  unfrequently  also 
hemorrhage  from  the  bowels.  Petechias  appear  on  the  skin. 
Prostration,  tremors  or  convulsions,  and  coma  end  the  history, 
usually  in  less  thaii  a  week. 

Secretions. — Marked  deficiency  of  urea  in  the  urine,  and  the 
presence  of  leucin  and  tyrosin  in  that  excretion,  have  been  re- 
marked. 

Morbid  Anatomy  and  Pathology. — The  liver  after  death  is^cff- 
tened  out  and  diminished  to  perhaps  less  than  half  its  normal 
size.  Its  cut  surface  has  a  yellow  color  like  rhubarb  ;  the  blood- 
vessels are  empty.  The  lobules  are  not  distinctly  marked,  many 
of  the  secreting  cells  being  destroyed  ;  in  their  place  are  masses 
or  spots  of  dark  bile-pigment,  fat,  and  htematin.  Zenker'  attrib- 
utes the  extremely  fatty  character  of  the  liver  contents,  in  many 
cases,  to  the  detritus  of  broken-down  cells.  The  kidneys  are  often 
found  in  a  state  of  partial  degeneration. 

Evidently  atrophy,  with  cessation  of  the  functional  action  of 

1  Schmidt's  Jahrbucher,  No.  10,  1873. 


808  DISEASES     OF    THE    LIVER. 

the  liver,  is  here  the  cardinal  fact.  Is  it  preceded  by  a  violent  and 
destructive  inflammatory  process  ?  Some  of  the  symptoms  would 
point  to  this.  Yet,  in  the  absence  of  autopsic  evidence,  uncom- 
mon as  primary  rapid  atrophy  seems  to  be  in  any  organ,  the 
precedence  of  inflammation  must  not  be  taken  for  granted. 
Grainger  Stewart  believes  it  to  be  primarily  a  blood  disease. 
The  cause  of  death  seems  to  be  cholsemic  poisoning.  The  resem- 
blance of  the  history  (and,  to  some  extent,  the  morbid  anatomy) 
of  this  affection  to  that  of  chronic  poisoning  by  phosphorus,  has 
been  pointed  out.^ 

Diagnosis. — From  acute  hepatitis  this  complaint  is  distinguished 
by  the  greater  amount  of  jaundice,  the  occurrence  of  hemorrhage 
from  the  stomach  or  bowels,  the  severe  headache  and  stupor ; 
but,  most  of  all,  by  the  diminution  of  dulness  on  percussion  over 
the  hepatic  region,  in  connection  with  symptoms  showing  violent 
disorder  of  the  liver.  Tlie  urine  will  also  be  found  after  evap- 
oration to  contain  tyrosin  and  leucin;  sometimes  in  crystalline 
deposits. 

Treatment. — ^Unless,  in  the  earliest  stage,  we  are  warranted  in 
endeavoring  to  promote  the  "unloading  of  the  portal  circle"  by 
mild  purgatives,  it  is  difficult  to  see  any  hopeful  indication  for 
treatment  in  this  affection,  other  than  palliation  of  fever,  if  there 
be  such,  by  diaphoretics,  aiding  the  depuration  of  the  blood  by 
diuretics  and  laxatives,  and  prolonging  life  by  appropriate  support. 
It  is  doubtful  whether  recovery  ever  takes  place  from  acute  yellow 
atrophy  of  the  liver. 

PIGMENT  LIVER. 

Frerichs,  Meigs,^  and  others  have  found  after  death  from  remit- 
tent fever,  or  in  patients  dying  from  other  diseases  after  exposure 
to  malarial  influence,  a  peculiar  condition  of  the  liver.  It  is  steel- 
gray,  or  blackish,  or  chocolate-colored  ;  presenting  brown  insu- 
lated figures  upon  a  dark  ground.  This  change  of  color  is  due 
to  the  accumulation  of  pigmentary  deposit  in  the  blood-vessels. 

The  spleen  is  somewhat  similarly  altered  ;  and  so,  to  a  less 
extent,  are  the  brain  and  kidneys.  The  blood  is  deficient  in  cor- 
puscles, and  contains  many  floating  particles  or  masses  of  pigment. 

Diagnosis. — During  life,  examination  of  a  few  drops  of  blood 
will,  in  some  cases  at  least,  display  the  abundance  of  free  pigment. 
The  skin  is  sallow  or  dull  yellow.  Enlargement  of  the  spleen, 
anasarca,  albuminuria,  diarrhoea  or  intestinal  hemorrhage,  and 
delirium  or  a  tendency  to  stupor,  may  occur.  There  is  but  little 
jaundice. 

Pathology. — The  scientific  interest  of  this  affection  turns  chiefly 
upon  the  proof  it  affords  of  the  effect  of  malarial  poison  in  disor- 
ganizing the  blood-corpuscles.  This  is  in  accordance  also  with  the 
remarkable  and  important  influence,  in  chronic  malarial  disease 
(as  obstinate  intermittent),  of  iron^  as  a  remedy. 

Treatment. — The  discovery  of  pigmentary  degeneration  or  de- 
posit in  the  blood,  or  the  supposition  of  its  occurrence  in  the  liver 

1  See  a  paper  by  Dr.  J.  Homans,  Am.  Journal  of  Med.  Science,  July,  1868,  p.  53;  and 
one  by  Dr.  W.  Pepper,  in  the  same  Journal,  April,  1869,  p.  347 ;  also  an  account  of  ex- 
periments by  Voit,  Med.  Times  and  Gaz.,  November  4,  1871. 

-  Meigs  and  Rboads,  Pennsylvania  Hospital  Reports,  vol.  1.,  1868. 


CIRRHOSIS.  309 

or  other  organs,  does  not  afford  any  now  or  special  indication  for 
treatment,  l)eyond  wliat  tlie  other  conditions  of  the  case  present. 
The  malarial  poison  is  to  be  antagonized,  and  the  system  is  to 
be  aided  in  restoring  the  disturbed  organs  and  functions  to  their 
normal  balance  ;  the  appropriate  means  for  which  ends  will  be 
considered  under  other  heads. 

CIREHOSIS. 

Synonyms, — Hob-nailed  liver,  gin-Uvcr. 

Anatomy  and  Pathology. — In  its  commencement  or  first  stage, 
cirrhosis  is  attended  by  some  increase  in  the  bulk  of  the  liver ; 
with  increase  also  of  its  firmness.  AVhen  the  disease  is  more  ad- 
vanced, the  organ  lessens  in  size,  especially  the  left  lobe ;  the 
induration  becomes  aggravated.  Knol)s  or  granulations  (nutmeg 
liver)  project  all  over  its  surface.  The  capsule  of  the  liver  is 
always  thickened. 

The  character  of  these  alterations  is  believed  to  be  due  to  the 
new  formation  of  connective  tissue,  in  the  ramifications,  through 
the  gland,  of  Glisson's  capsule.  Bands  of  this  material  constrict 
the  fobules,  obstructing  the  blood-vessels  and  bile-ducts,  as  well  as 
the  gland-cells.  Thus  divers  effects  are  produced.  Commonly 
the  subdivisions  of  the  portal  vein  are  diminished  in  size,  or  ob- 
literated ;  those  of  the  hepatic  artery  enlarged;  and  those  of  the 
hepatic  vein  unchanged.  The  biliary  ducts  are  at  first  distended 
by  partial  obstruction,  causing  repletion  of  the  cells ;  afterwards 
both  cells  and  ducts  maybe  in  considerable  part  destroyed.  The 
color  of  the  granulations  is  dark  or  pale  yellow.  Along  with  these 
changes,  in  'many  but  not  in  all  cases,  fatty  or  waxy  degeneration 
of  the  liver-structure  ensues. 

Inflammation  of  the  capsule  of  Glisson  and  its  interstitial  rami- 
fications has  been  considered  b}^  most  pathologists  to  be  the 
primary  element  of  cirrhosis.  Without  feeling  at  all  certain  of 
the  correctness  of  this  view,  I  am  unable  to  suggest  any  other  to 
take  its  place,  without  entering  upon  a  discussion  too  complex  for 
our  present  purpose.  The  principal  doubt  is,  in  regard  to  the 
change  which  occurs  being  properly  designated  as  an  inflammation. 

Laennec  (1819)  gave  the  name  of  cirrhosis  because  of  the  tav/ny 
yellow  color  of  the  liver.  Bouillaud  called  attention  to  the  pro- 
jection of  the  yellow  substance  in  nodules,  the  red  tissue  of  the 
liver  undergoing  atrophy.  Kiernan  (1836)  showed  that  the  ab- 
normal increase  occurs  chiefly  in  the  interstitial  connective  tissue  ; 
and  Klebs  (1868)  first  asserted  the  importance  of  early  inflamma- 
tion of  the  portal  venous  ramules  as,  probably,  the  beginning  of 
cirrhosis. 

Symptoms. — Nausea  and  indigestion,  with  furred  tongue  and 
slight  yellowness  of  the  skin  and  eyes,  are  the  earliest  (of  course 
not  i)a"thognomonic)  manifestations  of  this  disease.  Afterwards, 
mostly'with  slow  progress,  come  constipation,  vomiting,  emacia- 
tion, debility,  ascites,  with  or  without  general  dropsy,  and  enlarge- 
ment of  the  superficial  abdominal  veins.  This  last  sign  is  especially 
significant  of  obstruction  of  the  hepatic  circulation.  Towards 
the  close  of  life,  hemorrhage  from  the  stomach  or  bowels,  delirium, 
coma,  or  convulsions  are  apt  to  occur. 


310 


DISEASES    OF    THE    LIVER. 


Diagnosis. — From  acute  congestive  or  inflammatory  affections 
of  the  liver  the  slow  progress  of  cirrhosis  readily  separates  it. 
From  fatty  and  waxy  liver,  and  from  cancer,  it  is  distinguishable, 
though  not  always  with  ease,  by  the  continued  enlargement  of 
the  oro-an  in  those  affections  ;  while  they  are  also  less  constantly 
attended  by  dropsy  and  enlargement  of  the  abdominal  veins.  The 
spleen  is  often  enlarged  in  cases  of  cirrhosis.  This,  however, 
occurs  also  when  the  portal  vein  is  inflamed,  or  obstructed  either 
by  coagula  or  by  pressure.  There  is,  in  that  case,  apt  to  be  com- 
pression of  the  bile-ducts,  producing  decided  jaundice,  with  clay 
or  slate-colored  stools.  Chronic  peritonitis  is  sometimes  difficult 
to  diagnosticate  from  cirrhosis  ;  but  in  the  former  there  is  more 
abdominal  tenderness,  and  less  enlargement  of  the  superficial 
veins. 

Prognosis. — Recovery  from  cirrhosis  of  the  liver  is  not  to  be 
expected  ;  but  its  duration  varies  greatly,  and  may  be  favorably 
modified  by  regimen  and  treatment. 

Causation. — Although  malarial  influence  and  syphilis  may  pre- 
dispose to  it,  the  most  frequent  special  cause  of  cirrhosis  is  be- 
lieved to  be  alcoholic  poisoning.  It  is  one  of  the  most  common 
results  of  continued  intemperance. 

Treatment. — Having  the  hope  only  of  palliation  and  delay,  we 
must,  most  of  all,  prevent  the  persistent  action  of  the  cause,  by 
enforcing  abstinence  from  spirituous  liquors.  ISTourishing  diet  is 
at  the  same  time  very  important.  Milk,  if  well  digested  by  the 
patient,  meat,  or  concentrated  liquid  animal  food,  as  beef-tea, 
chicken-broth,  etc.,  will  be  suitable.  The  secretions  must  be 
attended  to.  Saline  laxatives,  especially  the  bitartrate  of  potas- 
sium, will  often  be  useful. 
Bitters  or  other  stomachics 
may  be  called  for  to  relieve 
nausea  and  strengthen  di- 
gestion. Dropsy  may  some- 
times require  tapping. 
Habershon  ^  advises  that 
this  be  done  early,  rather 
than  to  trouble  the  patient 
with  long-continued  medi- 
cation for  the  removal  or 
diminution  of  accumulated 
fluid. 


Fig.  103. 


FATTY  LIVER. 


This  form  of  degenera- 
tion is  not  uncommon  in 
intemperate  persons  or  in 
those  suffering  from  pro- 
longed debility,  as  in 
phthisis.  Perhaps  its  as- 
sociation with  the  latter  disease  is  the  most  frequent. 
In  its  diagnosis,  beyond  the  fact  of  enlargement  of  the  liver 


Fatty  Degeneration  of  Liver. 


1  On  the  Pathology  and  Treatment  of  some  Diseases  of  the  Liver;  London,  1872. 


WAXY    LIVEE.  311 

with  smooth  margin  and  surface,  in  an  enfeebled  constitution, 
unaircctcd  I)y  the  symptoms  of  otiier  hepatic  disorders,  unli'ss  it 
be  slight  jaundice,  there  is  nothing  positive.  The  change  may 
go  on  undiscovered  even  by  a  careful  observer,  until  after  death. 

Anatomically,  the  liver-cells  are  gorged  with  oil  ;  their  nuclei 
being  destroyed  or  ol)seured.  With  enlargement,  the  whole  organ 
presents  a  pale  and  tlabby  as  well  as  greasy  aspect ;  and  the  latter 
property  is  obvious  to  the  touch. 

There  is  no  treatment  especially  appropriate  to  this  affection, 
other  than  what  the  constitutional  state  will  point  out. 

WAXY  LIVER. 

Synon3rms. — Amyloid,  lardaceoics,  colloid  degeneration  of  the 
hver. 

This  is  often  an  accompaniment  of  fatty  degeneration  ;  but 
also  occurs  quite  frequently  without  it. 

Anatomy  and  Pathology. — The  waxy  liver  is  pale  or  mottled 
in  hue,  and  when  cut,  smooth,  hard,  and  dry.  It  is  heavier  than 
natural.  The  degeneration  probably  begins  in  the  lobular  rami- 
fications of  the  hepatic  artery,  and  extends  to  the  secreting  cells. 
Under  the  microscope  tliose  are  found  to  have  a  pearly  look,  and 
to  have  lost  their  cell-walls  and  nuclei.  The  acini'  or  lobules 
remain  very  distinctly  marked  out. 

Fatty  degeneration  may  coexist  with  the  waxy  ;  and  hence 
they  have  been  confounded  together.  The  weight  of  the  liver  is 
modified  (made  lighter)  by  the  presence  of  fatty  degeneration. 

The  term  anu/loidhas,  been  applied  to  the  waxy  or  colloid  change 
because  of  a  somewhat  starch-like  chemical  reaction  of  tlie  degen- 
erated material;  which  becomes  mahogany  red  (instead  of  yel- 
low) with  a  solution  of  iodine.  Laennec  and  Portal  noticed  the 
occurrence  of  waxy  liver,  but  confounded  the  change  with  fatty 
degeneration.  Koicitansky  (1842)  ascertained  the  occurrence  of 
the  same  sort  of  change  in  the  kidney  and  other  organs.  Virchow 
and  Meckel  (1853)  observed  the  violet  color  given  to  amyloid  ma- 
terial by  free  iodine.  Friedereich  (1860)  asserted  this  material 
to  be  not  starch-like,  but  albuminoid  in  nature.  It  is  stained 
of  a  red  or  violet  color  by  methyl-aniline  (methyl-green). 

This  kind  of  degeneration  is  almost  always  secondary.  It  is 
especially  apt  to  attend  upon  tuberculosis.  In  a  way  not  well 
understood,  it  often  follows  continued  suppuration,  in  difierent 
parts  of  the  body  ;  e.  g.,  caries  of  the  bones. 

Sjrmptoms  and  Physical  Signs. — Anaemia,  emaciation,  and 
dropsy  (often  with  vomiting  or  diarrhcea,  but  little  or  no  jaundice), 
unexplained  by  other  local  or  general  causes,  and  occurring  in  a 
scrofulous,  syphilitic,  or  malarial  diathesis,  may  justify  a  suspicion 
of  this  form  of  degeneration. 

Examination  confirms  this  if  we  also  find  the  liver  uniformly 
enlarged  and  firm,  with  at  the  same  time  enlargement  of  the 
spleen  and  albuminuria. 

Diagnosis. — Fatty  liver  does  not  exhibit  so  much  increase  in 
size  as  the  waxy,  and  the  latter  is  of  a  softer  consistence  upon 
pressure  ;  splenic  enlargement  and  albuminuria  less  often  attend 


812  DISEASES    OF    THE    LIVER, 

the  former ;  and  the  same  is  true  of  drops3\  Syphilitic  inflam- 
mation of  tlie  liver  differs  from  it  in  presenting  prominent  nodules 
ujoon  the  surface  of  the  organ. 

Causation.— Syphilis  is  the  most  common  predisposing  cause 
of  waxy  degeneration.  The  tubercular  constitution  probably 
comes  next.     It  exists  most  frequently  in  males. 

There  is  no  especially  indicated  treatment  for  this  affection. 

SYPHILITIC  LIVER. 

Among  the  organic  affections  now  recognized  as  displaying 
locally  the  effects  of  the  syphilitic  diathesis,  is  a  form  of  chronic 
hepatic  inflammatory  degeneration ;  that  is,  inflammation  fol- 
lowed by  a  specific  organic  change  of  structure. 

Anatomically,  the  liver  is  somewhat  enlarged  ;  with  an  uneven 
surface,  from  cicatrices  alternating  with  nodules.  This  uneven- 
ness  may  be  felt  upon  palpation  through  the  wall  of  the  abdo- 
men. The  patient  is  pale,  but  not  jaundiced  ;  and  dropsy  is  not 
present  as  a  symptom,  unless  from  other  organic  causes. 

In  diagnosis,  syphilitic  liver  is  to  be  distinguished  from  cancer 
of  the  liver  by  the  smaller  size  and  softer  consistence  of  the  pro- 
jecting nodules  in  the  former,  the  absence  of  tenderness  on  pres- 
sure, and  the  presence  of  the  signs  of  general  syphilis  ;  such 
as  the  marks  of  cicatrized  ulcers  in  the  throat,  copper-colored 
blotches  upon  the  skin,  or  nodes  upon  the  bones„ 

For  the  treatment  of  this  and  other  analogous  affections,  see 
Syphilis,  later  in  this  book. 

CANCER  OF  THE  LIVER. 

Mostly  in  middle  life,  but  occasionally  even  in  the  young,  cancer 
of  the  liver  occurs,  and  has  a  more  rapid  progress  than  most  can- 
cers. The  symptoms  are,  pain  in  the  right  side  and  shoulder,  with 
tenderness  in  the  right  hypochondriac  region,  disorder  of  the 
stomach  and  bowels,  rigidity  of  the  abdominal  muscles  (especially 
the  rectus),  debility,  emaciation,  a  cachectic  aspect,  and  ascites  or 
general  dropsy.  Sometimes,  however,  there  is  a  remarkable  ab- 
sence of  pain  and  of  other  symptoms,  until  a  comparatively  short 
period  before  death.^    There  is  usually  little  or  no  jaundice. 

Physical  exploration  shows  dulness  on  percussion  below  and 
above  the  usual  limits  of  the  liver  ;  and  on  palpation,  irregular 
prominences,  hard  in  most  cases,  but  sometimes,  in  encephaloid 
cancer,  soft  and  elastic.  The  enlargement  may  become  very  ex- 
tensive, and  then  all  the  effects  of  pressure  upon  the  portal  vein, 
etc.,  are  observed. 

Dr.  Huger,  of  Alabama,  reports  a  case  in  which  a  cancerous 
liver  was  found  after  death  to  weigh  15  pounds  lOJ  oz.  avoirdu- 
pois.    (Charleston  Med.  Journal,  April,  1874.) 

This  disease  is  always  fatal ;  affording  no  room  for  other  than 
merely  palliative  treatment.  Its  duration  is  often  less  than  six 
months  ;  seldom  more  than  a  year. 

1  See  cases  reported  by  Drs.  Glynn  and  Carter,  of  Liverpool;  Med.  Times  and 
Gazette,  Dec.  13, 1873. 


TUIJERCLE    OF    THE    LIVEIt.  318 

HY.DATIDS. 

These  are  clastic  tumors,  consisting  of  c?/.sis,  (levelopcd  around 
cchivococci.  The  latter  are  the  larvje  or  immature  progeny  of  a 
tcvnia;  they  are  fount!  not  only  in  the  liver,'  but  also  in  the  brain, 
muscles,  bones,  ovary,  uterus,  kidneys,  lungs,  heart,  spleen,  etc. 
The  sac  or  cyst  grows  slowly,  and  may  exist  for  years  without 
great  disturbance  of  the  health.  If  any  symptoms  occur,  they 
are  indigestion,  debility,  and  dropsj'. 

Hydatids  are  discovered  upon  inspection  and  palpation ;  the 
liver  being  considerably  enlarged,  so  as  to  press  up  the  diaphragm 
and  right  lung,  or  to  sink  far  down  into  the  abdomen.  On  per- 
cussion, besides  an  irregular  line  of  extended  dulness,  a  peculiar 
jelly-like  vibration  is  sometimes  perceptible  by  the  finger  used  to 
percuss  upon.  If  the  tumors  be  so  near  the  surface  and  so  evi- 
dently elastic  as  to  warrant  the  operation  of  exploration  with 
a  grooved  needle,  hypodermic  syringe,  or  asjiirator,  the  fluid 
drawn  out  will  be  very  characteristic.  It  is  colorless,  of  specific 
gravity  not  much  above  that  of  water  (1007-1010),  and  free  from 
albumen  ;  it  contains  a  large  amount  of  chloride  of  sodium. 

Sometimes  the  entozoa  within  the  cyst  die,  and  the  sac  collapses 
and  disappears.  In  other  cases  it  bursts  and  is  discharged  into 
the  alimentary  canal,  the  lungs,  or  externally  through  the  ab- 
dominal walls.  Slow  recovery  may  then  be  anticipated.  Danger 
always  exists,  however,  that  the  hjdatids  may  open  into  the 
pleural  or  peritoneal  cavity,  producing  pleurisy,  or  peritonitis.  In 
a  few  instances  supjDurative  inflammation  occurs  in  the  cyst. 

In  the  treatment  of  hydatids  some  physicians  have  been  dis- 
posed to  confide  in  the  supposed  power  of  iodide  of  potassium, 
and  of  chlorate  of  potassium,  taken  internally,  to  cause  the  ab- 
sorption of  the  fluid  of  the  cyst,  and  thus  destroy  the  parasite. 
But  the  evidence  does  not  appear  to  be  sufficient  to  justify  such 
confidence. 

Very  large  and  superficial  hydatids  may,  when  the  diagnosis 
is  clear,  be  tap]jcd^  with  at  least  temporary  relief  to  the  patient. 
Should  this  be  safely  done  without  cure,  it  may  be  repeated,  and 
then  a*  gum-elastic  tube  may  be  introduced  and  retained  in  the 
opening,  so  as  by  drainage  to  induce  the  shrinking  of  the  cyst 
and  thus  the  destruction  of  the  echinococcus.  Dr.  Pavy  reports 
success  in  one  case  with  injection  of  male  fern  into  a  hydatid  cyst 
of  the  liver ;  its  anthelmintic  or  parasiticide  power  seeming  to  be 
thus  shown.  Skoda  has  reported  the  cure  of  a  case  of  large  hydatid 
in  the  left  hypochondrium,  by  injections  of  solution  of  iodine,  left 
in  each  time  for  thirteen  minutes. 

TUBERCLE   OF  THE   LIVER. 

Primary  tuberculization  of  the  liver  is  never  met  with.  In 
patients  dying  with  phthisis,  not  unfrequently  miliary  tubercular 
deposits  are  found  scattered  over  the  gland  ;  they  rarely  soften, 
but  sometimes  small  vomkm  are  met  with.  It  is  of  course  neces- 
sary to  be  aware  of  the  possible  existence  of  such  formations,  in 
the  consideration  of  the  morbid  anatomy  of  the  liver. 

1  Of  508  cases  of  hydatids,  Cobbold  and  Davaine  found  the  liver  to  be  affected  in  21(>. 
27 


314  SPLEEN. 

DILATATION   OF  THE  GALL-BLADDER. 

This  may  be  produced  by  obstruction  of  the  gall-duct  or  the 
common  bile-duct,  or,  more  rarely,  by  a  morbid  formation  of 
serous  fluid  within  it,  allied  to  a  local  dropsy.  The  diagnosis  of 
this  may  be  important,  as  it  may  be  readily  confounded  with 
hepatic  enlargement.  It  is  to  be  distinguished  from  cancer  by  the 
great  amount  of  jaundice  (in  most  cases),  the  previous  occurrence 
of  gall-stone  colic  (also  not  invariable),  and  the  more  uniform  and 
softer  character  of  the  swelling.  From  hydatids  the  same  signs, 
except  the  softness  of  the  tumor,  are  distinctive  ;  and  hydatids 
grow  much  more  slowly. 

For  the  treatment  of  dilatation  of  the  gall-bladder,  the  remedies 
suitable  for  obstruction  of  the  biliary  ducts  will  be  appropriate. 
Surgical  interference  is,  in  any  case,  bold  practice ;  unless,  per- 
haps, by  pneumatic  aspiration.  The  operation  of  cholecystotomy 
(puncturing  or  incising  the  gall-bladder)  for  removal  of  gall-stones, 
has,  however,  several  times  been  performed  ;  in  a  few  instances 
with  success.  Although  proposed  by  Petit  (1733),  and  several 
others  since,  the  first  recorded  example  of  it  (except  one  men- 
tioned in  Good's  Study  of  Medicine^  1855,  without  particulars)  was 
that  of  Dr.  Bartholow,  in  1876.  G.  Brown,  Marion  Sims,  W.  W. 
Keen,  Bryant,  Lawson  Tait,  and  Calhoun  have  followed  ;  the  last 
three,  with  recovery  of  their  patients.^ 

Perforation  of  the  gall-bladder  or  gall-duct  now  and  then  occurs, 
from  prolonged  obstruction  and  dilatation.  This  must  prove  fatal 
(as  in  a  case  referred  to  upon  a  previous  page)  by  the  production 
of  peritonitis,  from  the  escape  of  bile  into  the  peritoneal  cavity. 

Gall-stones  are  alluded  to  under  "Bilious  Colic," 


ArrECTIONS  OF  THE  SPLEEK. 

These  are  necessarily  treated  of  at  length  in  extended  syste- 
matic treatises.  It  will  be  enough  for  our  purpose  to  say  a  very 
few  words  of  them.  The  spleen"  is  commonly  enlarg'ed  in  inter- 
mittent, remittent,  and  typhoid  fevers  and  in  leucocythcemia ;.  some- 
times, in  pregnancy  (Simpson).  Rupture  of  the  spleen,  causing 
death,  has  been  several  times  reported.  Such  an  affection  (i.  e,, 
rupture  of  the  spleen)  could  scarcely  be  diagnosticated  during 
life. 

Enlargement  of  the  spleen  is  readily  ascertained  by  inspection 
and  palpation.  It  often  increases  and  diminishes,  during  and 
between  the  paroxysms  of  intermittent  (ague-cake).  iPiorry 
asserted  its  rapid  diminution  under  cinchonization.  Some  prac- 
titioners have  found  it  to  diminish  under  hypodermic  injections  of 
ergotinj  Faradaic  electrization  will  also  have  a  similar  effect. 
Other  affections  of  the  spleen  (inflammation,  tubercle,  hydatids, 
etc. )  are  so  generally  difficult  of  diagnosis  as  to  have  chiefly  a 
post-mortem  interest ;  and  they  present  no  clearly  recognized 

1  See  papers  on  the  subject  by  Dr.  W.  W.  TCeen,  Amer.  Journal  of  Med.  Sciences, 
January  and  April,  1879  ;  and  by  Dr.  C.  W.  Calhoun,  of  Turkey  in  Asia,  in  N.  Y.  Med. 
Becord,  Jan,  29,  1881,  p.  116. 

2  Da  Costa,  Amer.  Jour,  of  Med.  Sciences,  Jan.,  1875. 


UR^.MIA.  315 

indications  for  treatment.  About  forty  cases  have  been  reported  * 
in  which  the  spleen  was  removed  entirely  ;  more  than  half  of 
the  patients  recovered. 

AFFECTIONS  OF  THE  KIDNEYS  AND  BLADDER. 
CONGESTION. 

Causation. — Under  exposure  to  cold,  overdoses  of  cantharidcs 
or  turpentine,  or  the  disturbance  belonging  to  different  inllamma- 
tory  and  febrile  complaints,  active  renal  congestion  may  occur. 
Pasdve  congestion  is  more  common  in  heart-disease,  or  pulmonary 
obstruction,  as  by  pleuritic  ellusion  or  emphysema,  or  when  press- 
vire  impedes  the  circulation  in  the  renal  veins  or  ascending  vena 
cava,  as  in  pregnancy  or  abdominal  tumors. 

Symptoms.— Pain  in  the  lumbar  region,  sometimes  with  tender- 
ness on  pressure  on  each  side  of  the  spine.  Scanty  urination,  the 
fluid  being  high-colored,  sometimes  bloody,  or  containing  albu- 
men. Certain  cases  exhibit  under  the  microscope  fibrinous  casts  ; 
epithelial  cells  are  commonly  met  with. 

Diagnosis. — It  is  only  occasionally  difficult  to  distinguish  this 
condition  from  Bright's  disease.  Active  congestion  begins 
aln-uptly  under  a  recognizable  cause.  Passive  congestion  shows  a 
dependence  upon  some  other  organic  affection,  and  although 
variable,  is  not  progressive.  They  are  thus  distinguishable  from 
advancing  and  more  or  less  permanent  disease  of  the  kidneys. 

Treatment.— For  active  congestion,  cupping  the  lumbar  region 
is  proper,  abstracting  blood  in  amount  proportioned  to  the  state 
of  the  patient.  Purgation  may  follow,  by  castor  oil  or  citrate  or 
sulphate  of  magnesium.  Then,  the  warm  bath  or  hip-bath,  con- 
tinued for  some  time. 

uk.i:mia. 

Definition.— The  retention  in  the  blood  of  the  material  which  it 
is  the  function  of  the  kidneys  to  excrete  ;  from  the  suppression  of 
their  action. 

Symptoms.— When  well-marked,  headache,  dimness  of  vision, 
vomiting,  diarrhoea,  convulsions,  and  stupor;  ending  in  fatal 
coma. 

The  temperature  of  the  body  is  generally  above  the  normal 
degree.  This  aids  in  the  diagnosis  between  ursemic  coma  and 
opfum  poisoning  ;  in  which  the  temperature  is  lower  than  natural. 

Pathology.— The  question  as  to  what  is  the  immediate  toxic 
agent  in  urjemia  is  not  yet  fully  determined  ;  i.  e.,  whether  it  is 
urea,  or  an  ammoniacal  educt  from  its  decomposition  in  the  blood. 
In  the  absence  of  demonstration  of  the  latter,  the  former  appears 
probable.  A  further  view  has  been  urged  ;  that  it  is  unchanged 
creatin,  creatinin,  and  other  extractives,  that  contaminate  the 
blood.     (See  BrighVs  Disease.) 

The  term  iirinceynia  is  a  safe  one,  not  involving  either  of  these 

1  London  iMed.  Times  and  Gazette,  Dec.  7,  18G7.  This  is  less  extraordinary  than 
Prof.  a.  Simou's  ease  (Deutsche  Kliuik,  April,  1870),  in  which  he  extracted  successively 
the  left  ovary,  the  uterus,  and  the  left  kidney ;  and  the  patient  recovered.  See  also 
Am.  Jour.  Mod.  Sci.,  April,  1878,  and  April,  1879. 


316       DISEASES   OF   KIDNEYS    AND  BLADDER, 


opinions.  Traube  has  proposed  the  hypothesis  that  the  ursemic 
symptoms,  so  considered,  in  Bright's  disease,  may  depend  upon 
oedema  of  the  brain. 

Treatment. — This  must  vary  with  the  circumstances  of  the 
production  of  the  suppression  ;  but  the  great  indication  is  to 
depurate  the  blood  — by  the  kidneys,  if  they  can  be  restored  to 
action,  and  by  the  aid  or  substitution  of  the  bowels  and  skin.' 
For  this  end,  the  warm  bath,  or  the  hot-air  or  warm  vapor  bath 
may  be  of  great  service.  In  acute  sthenic  cases,  moderate  vene- 
section will  do  good.  So  may  cupping,  hot  poultices  or  counter- 
irritation  by  mustard  or  tincture  of  iodine  over  the  small  of  the 
back.  Dr.  B.  W.  Richardson  has  especially  urged  venesection  as 
the  most  hopeful  remedy  for  uraemia.  Saline  cathartics,  even 
hydragogues,  may  be  given  to  such  patients  as  have  sti'ength  to 
bear  them  ;  as  cream  of  tartar,  Epsom  salts,  elaterium,  or  croton 
oil ;  the  last  two  most  rarely.  Lemonade  drunk  freely  is  often 
one  of  the  best  of  diuretics.  Others  will  be  mentioned  hereafter, 
in  connection  with  Dropsy.  Dr.  A.  L.  Loomis  has  reported  suc- 
cessful results  in  the  treatment  of  ursemic  convulsions  with 
hypodermic  injections  of  morphia.^ 

NEPHRITIS. 

In  the  present  state  of  urinary  pathology,  it  is  common  to 
merge  the  topic  of  inflammation  of  the  kidney  (except  suppura- 

FiG.  104. 


Deposits  from  Urine  in  Renal  Hyiiersemia. 

tive  pyelitis)  as  distinct  from  active  renal  congestion — in  Bright's 
disease.  If  this  be  questionable  as  a  matter  of  pathological  system, 
it  has  at  least  practically  no  disadvantage  ;  as  the  symptoms  of 
nephritis  are  included  in  one  or  other  of  the  affections  named ; 

1  There  is  reason  to  believe  (Cyon)  tliat  tlie  liver  also  aids  in  the  separation  of  urea 
from  the  blood. 

2  N.  Y.  Medical  Record,  August  1,  1873. 


BRIGHT    .S     DISEASE, 


317 


and  so  is  its  treatment.  We  may  submit  tliereforo  to  the  usas;e 
of  authority  upon  tliis  point,  without  liesitation.  The  symptoms 
of  acute  2)!/clitis  (intlammation  of  tlic  pelvis  of  the  kidney)  are 
essentially  those  of  renal  con!j;estion,  intcnsilied  ;  with  tenderness 
on  pressure  over  tlu^  kidney,  and  fever,  until  suppuration  is  estab- 
lished ;  then,  purulent  discharge  for  a  variable  time  from  the 
kidneys.  (See  ryonephrosis.)  Before  pus  appears,  blood,  in 
small  quantity,  mucus,  and  renal  epithelial  cells  may  be  found 
in  the  urine.  A  tumor  in  one  of  the  lumbar  regions  may  precede 
for  a  while  the  escape  of  pus. 


BKIGHT'S  DISEASE. 

Definition. — Albuminuria,  dependent  upon  structural  change 
in  the  kidneys  ;  or,  more  cor- 
rectly, disease  of  the  kidney, 
characterized  usually  by  al- 
buminuria and  dropsy. 

Varieties  or  Stages.— Au- 
thorities differ  as  to  the  dis- 
crimination of  these.  Bright 
believed  there  were  three 
varieties.  Dr.  G.  Johnson 
asserts  two  — the  desquama- 
tive and  non-desquamative 
nephritis.  Frerichs  con- 
siders them  to  be  grades  of 
the  same  affection,  and 
admits  three  stages,  essen- 
tially of  hypereemia,  exu- 
dation, and  degeneration. 
Anatomically,  we  have  the 
large,  smooth,  white  kidnei/ ^the 
small,  smooth  kidney,  the  gran- 
ular uncontracted  kidney,  and 
thegranidarcontractedkidney. 
"We  may  safely  follow  Rob- 
erts, dividing  Bright's  dis- 
ease, first  into  acute  and 
chronic.  The  latter  is  then 
divided  into,  1.  Cases  which  have  lapsed  from  the  acute  state 
(smooth,  white,  generally  large  kidney) ;  2.  Cases  slow  or  chronic 
from  the  beginning  (granular,  red,  contracted  kidney) ;  3.  Cases 
associated  with  waxy  or  amyloid  degeneration  of  the  kidneys. 

Causation. — Bright's  disease  is  one-third  more  common  in 
males  than  in  females.  The  greatest  number  of  cases  occurs 
between  the  ages  of  45  and  65.  Acute  Bright's  disease  is  most 
often  produced  by  cold  and  dampness  ;  next  by  scarlet  fever, 
pregnancy,  or  violent  intemperance.  Malaria  is  also  to  be 
inctuded  among  its  causes.^  The  acute  form  is  most  common  in 
early  life. 

Chronic  Bright's  disease  also  is  greatly  promoted  by  exposure 


^1 
Renal  Cysts  (dilated  tubules). 


1  Busey,  Am.  Jour,  of  Med.  Sciences,  January,  1873. 


27 


318      DISEASES   OF   KIDNEYS   AND   BLADDER. 


to  cold  and  wet ;  it  is  caused,  moreover,  very  often,  by  abuse  of 
spirituous  liquors.  Other  predisposing  causes  are  gout,  valvular 
disease  of  the  heart,  constitutional  syphiUs,  and  affections  of  the 
bladder  and  urethra.  Climate  must  have  something  to  do  with 
it ;  as  the  ratio  of  deaths  from  renal  disease  to  all  deaths  is,  in 
London  1  to  49,  Paris  1  to  226,  Bombay  1  to  2800,  and  Genoa  1 
to  4303.^ 

Symptoms.    Acute  Bright's  Disease.— After  exposure  to  cold, 
or  a  drunken  fit,  or  scarlet  fever,  the  patient  is  seized  with  chilli- 

FiG.  106. 


Casts,  in  Bright's  Disease,   a  a.  Epithelial  Casts,  b  b.  Opaque  Granular  Casts. 

ness,  headache,  nausea,  vomiting,  pain  in  the  back  and  limbs, 
checking  of  perspiration,  and  oppression  in  breathing.  Fever 
follows,  and  the  face,  trunk,  and  limbs  become  puffy  with  anasarca. 
Effusion  may  also  occur  into  the  pleura  or  peritoneum. 

The  urine  is  scanty,  heavy,  acid  in  reaction,  and  dark  in  color, 
from  the  presence  of  blood  ;  and  very  albuminous.  The  disposi- 
tion to  void  it  occurs  more  frequently  than  during  health.  The 
deposit  from  it,  under  the  microscope,  shows  blood-corpuscles, 
loose  renal  epithelium,  free  nuclei,  tube-casts,  and  shapeless 
masses  of  fibrin  and  debris. 

After  one,  two,  or  three  weeks,  or  even  a  longer  period,  the 
attack  proceeds  to  one  of  three  terminations  :  recovery,  death, 
or  lapse  into  the  chronic  state.  Death  results  through  uraemia, 
or  from  secondary  pneumonia,  pleurisy,  peritonitis,  pericarditis 
— or  hydrothorax,  oedema  of  the  glottis,  hydrocephalus,  or 
ascites.  Probably  two-thirds  or  more  of  the  cases  of  acute 
Bright's  disease  recover. 

1  See  a  paper  by  Dr.  A.  Flint,  New  York  Medical  Record,  July  15, 1869. 


BTITGHTS    DISEASE. 


319 


Treatment.— Cupping  the 
"  blanket "  bath  ;  active  purg- 
ing, as  witli  cream  of  tartar 
and  jalap,  or  citrate  of  mag- 
nesium ;  and  dia[)horetics,  as 
citrate  of  potassium,  or  liquor 
amnion,  acetat.  Mercury  is 
not  recommended.  The  diet 
should  be  liquid  and  simply 
nutritious. 

Chronic  Bright's  Disease. 
^This  approaclics  so  slowly 
as  seldom  to  be  detected  until 
after  the  lapse  of  months 
or  years.  Gradual  loss  of 
strength,  pallor  or  puffiness 
of    the     face,    shortness     of 


loins,    hot    water    or    hot-air    or 


Incipient  Gianular  Degeneration  of 
Kidney 


breath,  and  frequent  disposition  to  urinate,  are  early  signs  of 
it.  But  they  are  not  always  present  •,  the  denouement  of  the  dis- 
ease may  be  by  a  convulsion,  oedema  of  the  lungs,  amaurosis,  or 
some  violent  local  inflammation. 

Symptoms  and  signs  of  a  well-marked  case  (not  all  present  in 
every  instance)  are  :  albuminous  urine,  deposits  of  tul)e-casts 
and  renal  epithelium,  dryness  of  skin,  frequent  micturition,  espe- 
cially at  night,  general  dropsy,  or  local  effusions  into  the  cav- 
ities, indigestion,  ancemia,  ursemic  effects  (headache,^  dizziness, 
impairment  of  sight,^  convulsions,  coma,  vomiting,  diarrh(jea), 
enlargement  of  the  heart,  and  secondary  inflammations.  Bron- 
chitis is  especially  common. 

The  progress  of  the  case  is  usually  interrupted  by  exacerba- 
tions and  intervals  ;  each  fresh  attack  leaving  the  patient  man- 
ifestly worse  than  before.  Such  attacks  much  resemble  acute 
Bright's  disease  ;  they  are  sometimes  referred  to  known  causes  ; 
the  intervals  may  last  weeks,  months,  or  even  years. 

In  prognosis,  the  tendency  is  always  towards  a  fatal  result. 
About  one-third  die  of  ureemic  poisoning.  A  considerable  num- 
ber die  of  local  dropsical  eft'usions.  One-fifth  from  secondary 
pneumonia,  pericarditis,  or  pleurisy.  The  rest,  by  exhaustion, 
from  ansemia,  indigestion,  and  anasarca,  or  the  complications  of 
apoplexy,  cirrhosis,  phthisis,  intestinal  ulcerations,  etc. 

Diagnosis. — The  presence  of  albumen  in  the  urine,  with  dropsy, 
not  of  sudden  origin  or  brief  duration,  is  pathognomonic  of  this 
aftection.  The  tests  for  albumen,  by  heat  and  nitric  acid,  are 
readily  applied.  The  microscope  will  show  also  free  renal  epithe- 
lium and  tubular  casts  in  the  urine  ;  in  advanced  cases  the  casts 
are  sprinkled  with  oil-dots.  The  solids  of  the  urine,  especially 
the  urea,  are  reduced  below  the  normal  amount. 

1  Occipital  headache  is  (Seguin)  one  of  the  signs  of  uraemia. 

2  Prof.  J.  Green,  of  St.  Louis,  has  well  described  the  ophthalmoscopic  signs  of  albu- 
minous retinitis  in  Bright's  disease.  There  are  usually  white  stellate  spots  on  the 
retina,  with  enlargement  of  the  retinal  blood-vessels.  TUrck  and  others  regard  the 
affection  of  the  retina  as  a  fatty  degeneration.  Dr.  Gouverncur  Smith,  of  New  York, 
remarks  that  dulness  of  hearing  also  occurs  under  similar  causation,  in  some  cases  of 
Bright's  disease.    See  Trans,  of  N.  Y.  Academy  of  Medicine,  1869. 


820      DISEASES   OF   KIDNEYS   AND  BLADDER. 

Pathology. —  Degeneration  of  the  structure  of  the  kidney 
(usually  following  interstitial  inflammation)  induces  albumin- 
uria, by  allowing  the  serum  of  the  blood  to  pass  almost  un- 
changed through  the  cortical  substance  into  the  tubuU  uriniferi. 
The  deficiency  of  urea  is  due  to  the  same  impairment  of  secreting 
power.  The  smooth  white,  generally  large,  kidney  is  the  result 
of  fatty  degeneration  ;  this  either  following  an  inflammatory 
attack,  or  being  primarily  a  chronic  atrophic  affection.  Dr.  T. 
Grainger  Stewart  describes  three  forms  of  change  :  1.  The  inflam- 
matory form,  with  three  stages  :  a,  that  of  inflammation  ;  &,  fatty 

Fig. 108. 


Benal  Epithelium,  a,  Normal,    b,  Atrophied,    c,  Fatty  Degeneration, 

transformation  ;  c,  atrophy.  2.  The  waxy  or  amyloid  form,  also 
with  three  stages :  a,  degeneration  of  vessels ;  h,  secondary 
changes  in  the  tubes  ;  c,  atrophy.  3.  The  cirrhotic,  contracting 
or  gouty  form.  Dickinson  especially  has  shown  the  importance 
of  the  distinction  into  tubal,  interUibal,  and  vascular  disease.  Dr. 
George  Johnson  has  proved  that  in  Bright's  disease  the  coats  of 
the  small  arteries  in  various  parts  of  the  kidney  become  thick- 
ened with  hypertrophy.  An  early  change  in  the  arteries  seems 
to  be  a  part  of  most  organic  degenerations.  Runeberg  ^  suggests 
the  occurrence  of  an  abnormal  permeability  of  the  blood-vessels 
of  the  Malpighian  tubes,  as  allowing  the  transudation  of  serum 
albumen. 

Sir  Wm.  Gull  and  Dr.  H.  G.  Sutton^  advance  the  view  that  the 
affection  of  the  kidneys  is  only  a  part  of  a  morbid  process  going 


1  Deutsche  Archiv  f.  Klin.  Med.,  vol.  xxiv.,  p.  248. 

2  Medico-Chirurgical  TranxSactions,  vol.  Iv.,  1872. 


B  R  I  G  II  '1^ '  S     DISEASE. 


321 


on  in  the  general  vascular  system  ;  to  which  thoy  c;ive  the  name 
"arterio-capillary  lihrosis. "  '  In  tlie  vessels  of  tlu;  allected  kid- 
ney, two  kinds  of  clian<j;e  may  occur;  one,  defeneration  of  the 
arteries  ;  the  otiier,  thickening  of  their  muscular  walls.  It 
appears  improhal)le  that  these  alterations  should  occur  tojfether. 
It  is  to  he  inferred,  from  all  the  facts,  that  when  the  disease  is 
tubal  (intratuhal)  in  its  origin  and  seat,  mimnilm-  hypertrophy  of 
the  renal  arteries  results  as  an  eflect  of  the  ahnormal  resistance  to 
the  flow  of  blood  (as  does  also  cardiac  hypertrophy  in  the  same 
case)  ;  while  many  instances  also  are  observed  in  which  the  later 

Fig.  109. 


Waxy  Casts. 

morbid  alteration  is  intertuhal,  consisting  of  arterial  fibrosis  or 
other  degeneration  of  the  vessels. 

Da  Costa  and  Lougstreth,'  on  the  basis  of  several  autopsic 
examinations,  assert  the  view  that  a  morbid  aflection  of  the 
nerve-ganglia  of  the  renal  plexus  precedes  the  disorder  of  the  kid- 
neys ;  giving  a  primary  neurotic  origin  to  the  aflection. 

Bamberger,  of  Vienna, -  insists  that  parenchymatous  and  tubu- 
lar nephritis,  as  well  as  amjdoid  degeneration  of  the  kidney, 
are  very  common  secondary  accompaniments  of  tubercular 
phthisis. 

In  regard  to  the  immediate  source  of  the  albumen  in  the  urine, 
evidence  predominates  that  it  transudes  from  the  "glomeruli" 
or  capillary  tufts  of  the  kidney.     Litten  considers  its  origin  to 


1  Am.  Journal  of  Med.  Sciences,  July,  1880. 

*  Volkmann's  Saninilung  Klinischer  Vortrage,  No.  178. 

V 


322       DISEASES   OF   KIDNEYS    AND   BLADDER. 

be,  in  an  early  stage,  dilatation  of  those  capillaries ;  later,  their 
degeneration.^ 

After  having  myself  held  for  many  years  that  (as  above  stated) 
the  arteries  and  the  heart  both  alike  undergo  hypertrophy  in  con- 
sequence of  the  obstruction  to  the  normal  flow  of  blood  into  the 
diseased  kidneys,  it  is  a  gratification  to  find  this  view  supported 
by  Dr.  W.  H.  Dickinson,''  of  St.  George's  Hospital,  London. 

As  for  the  mode  of  death  in  Bright's  disease,  it  appears  reason- 
able to  refer  it  to  uraemia  (urinsemia.)  Jaksch  and  Treitz  have 
used  the  term  ammonsemia,  to  indicate  a  supposed  poisoning  by 
ammonia  or  its  salts.  But  the  amount  of  ammonia  ever  present 
at  once  in  the  blood  is  not  likely  to  be  sufficient  to  produce  toxic 
effects.  Urea,  moreover,  according  to  the  experiments  of  Feltz, 
Bitter,  and  others,  appears  to  be  innocuous.  The  precise  nature 
of  urinsemic  poisoning  continues,  therefore,  to  be  as  yet  unex- 
plained. 

It  is  probable  that  the  transitory  condition  producing  albumin- 
uria after  scarlet  fever,  or  during  diphtheria  or  other  acute  dis- 
orders, has  no  necessary  relation  to  chronic  Bright's  disease. 
The  latter,  there  is  reason  to  suppose,  may  be  non-inflammatory 
and  degenerative  from  the  first.  Yet,  where  a  predisposition 
exists,  an  inflammatory  attack  may  promote  it,  as  with  other 
degenerations. 

Treatment. — The  indications  in  every  case  of  Bright's  disease 
are  :  1.  To  hinder  the  progress  of  structural  change  in  the  kid- 
ney ;  2.  To  prevent  ursemia  and  secondary  inflammation  ;  3.  To 
palliate  concomitant  symptoms  or  states,  as  anaemia,  dropsy, 
dyspepsia,  etc. 

Eegimen  or  hygienic  management  is  of  the  utmost  importance 
for  the  first  of  these  ends.  Avoidance  of  exposure  to  cold,  wet, 
or  fatigue,  reform  from  intemperance,  if  it  has  existed,  or  from 
other  excesses,  will  be  indispensable.  Clothing  should  be  suffi- 
ciently warm,  with  flannel  next  to  the  skin.  Bathing  frequently, 
at  such  temperature  as  is  borne  without  chill  or  relaxation,  is  to 
be  recommended.  The  bowels  should  be  kept  regularly  open. 
Nourishing  diet,  of  which  milk  may  generall}'^  be  part,  is  of  con- 
sequence. Yet,  to  give  the  kidneys  as  little  work  of  elimination 
as  possible,  it  is  desirable  that  the  amount  of  nitrogenous  (espe- 
cially animal)  food  taken  should  be  limited. 

Iron  v/ill  do  more  good  than  any  other  medicine,  unless  it  be 
cod-liver  oil  with  persons  of  strong  stomach.  These  medicines 
may  be  very  well  combined.  The  tincture  of  the  chloride  of  iron 
is  as  good  as  any  other  chalybeate,  as  a  general  rule.  With  some, 
the  citrate  of  iron  in  solution,  or  the  carbonate  or  the  iodide  will 
agree  more  readily.  Iodide  of  potassium  is  lauded  by  Cryni,  of 
Brussels,  and  others.  In  the  albuminuria  of  pregnancy  and  of 
scarlet  fever.  Dr.  W.  S.  Hill,^  of  Maine,  has  found  benzoic  acid 


1  Perls  (1880),  followed  by  Posner,  Litton,  and  others,  applied  coagulation  by  heat  to 
the  post-mortem  investigation  of  disease  of  the  kidneys  and  other  organs.  By  this 
metliod,  in  the  "large  white  liidney,"  the  capsules  and  uriniferous  tubules  have  been 
shown  to  be  distended  with  albuminous  fluid.    See  Lancet,  March  20,  1880. 

2  A  Treatise  on  Albuminuria,  2d  edition,  1881. 

3  Amer.  Journal  of  Med.  Sciences,  July,  1881,  p.  169. 


LITHIASIS.  323 

(about  two  grains  every  four  hours)  very  beneficial.  It  may  do 
good  also  in  some  cases  of  Bright's  disease. 

It  is  very  doubtful  whether  astringents  ever  check  to  advantage 
the  waste  of  albumen  through  the  kidneys.  If  any  be  worth  the 
trial,  it  is  amuKmio-ferric  alum.  Counter-irritants  over  the  kid- 
neys, unless  of  the  mildest  character  (tinct.  iodin.  emplastr.  picis, 
etc.),  will  not  do  any  important  good  in  chronic  Bright's  disease. 

For  the  dropsy,  warm  baths  and  hydragogue  cathartics  are 
advised.  Of  the  latter,  cream  of  tartar  and  jalap  together  are 
favorites  ;  2  or  3  drachms  of  the  bitartrate  with  10  to  20  grains 
of  jalap  two  or  three  times  a  week.  If  serious  dropsical  accumu- 
lation threaten  life,  elaterium  (gr.  I  or  I  every  four  hours,  in  pill, 
till  it  acts)  may  be  given.  But  it  is  a  decided  mistake  to  harass 
the  patient  constantly  with  exhausting  purgation.  It  is  to  be 
remembered  that  it  can  act  only  as  a  palliative^  removing  part  of 
the  cffcvta  of  the  malady,  not  the  disease  itself.  Da  Costa  has 
recorded'  a  case  of  recovery  from  acute  Bright's  disease  under 
drachm  doses  of  jahorandi,  thrice  daily,  producing  copious  sweat- 
ing and  urination. 

If  the  warm  bath  do  not  agree,  or  fail  to  produce  diaphoresis, 

those  who  have  access  to  it  should  try  the  hot-air  hath^  at  130°  to 

150°  Fahr.     This  rarely  fails  to  produce  free  perspiration.     For 

,  weaker  invalids  the  vapcn*  bath  is  available  ;  or  the  hot-sand  bath. 

Of  diuretics,  acetate  of  potassium,  spirit  of  nitrous  ether,  and 
infusion  or  compound  spirit  of  juniper  will  be  the  least  likely  to 
disappoint.     But  all  will  not  unfrequently  fail. 

Then  we  have  a  resource  (where  tapping  for  ascites  is  not 
demanded)  for  the  relief  of  great  a'dema,  in  the  use  of  incisions 
with  a  lancet,  or  needle,  in  the  swollen  legs  and  feet.  I  prefer  a 
number  of  small  incisions  with  an  abscess  lancet,  plunged  through 
the  skin  of  the  calf  and  dorsum  of  the  foot.  It  is  just  possible 
that  erysipelas  may  follow  ;  but  this  danger  will  be  lessened  by 
repeated  warm  sponging  of  the  limbs,  washing  them  with  diluted 
glycerin,  or  inunction  with  lard  or  cold  cream. 

For  unenda,  blood-letting  (W.  Roberts)  is  a  i)owerful,  but,  on 
account  of  debility,  a  rarelij  applicable  remedy.  We  can,  indeed, 
usuall}'  do  nothing  for  this  condition  other  than  to  urge  all  those 
measures  which  promote  secretion,  especially  of  the  kidneys,  skin, 
and  bowels  ;  to  which  allusion  has  above  been  made.  Jaborandi 
(or  pilocarpin)  has  been  considerably  employed  for  such  action 
in  recent  practice.  Dr.  Prentiss,  of  Washington,  has  reported'^ 
a  remarkable  case  in  which  pilocarpin  gave  relief  after  eleven 
days  of  suppression  of  urine. 

The  complications  of  Bright's  disease  must  be  treated  according 
to  their  own  indications,  on  general  principles,  bearing  in  mind 
always  the  degenerative  and  asthenic  tendencies  belonging  to  the 
malady  itself. 

LITHIASIS. 

Definition. — The  formation  of  calculous  deposits  (gravel  or 
stone)  in  the  kidneys  or  bladder. 

I  Hospital  Gazette,  1879.  2  Phila.  Med.  Times,  July  2. 1881. 


324      DISEASES   OF  KIDNEYS   Al^TD   BLADDER. 

Causation. — Stone  is,  by  statistics,  nearly  ten  times  as  frequent, 
or  at  least  as  fatal,  in  the  male  as  in  the  female.  It  destroys  life 
most  often  after  fifty  years  of  age  ;  but  is  far  from  uncommon  in 
early  life,  even  under  five  years.  Locality  has  something  to  do 
with  the  causation  of  stone  and  gravel.  They  are  common  in 
England,  Scotland,  Iceland,  France,  jSTorthern  Italy,  and  Egypt, 
and  uncommon  in  Ireland,  Sweden,  Norway,  and  Austria.  In 
this  country  they  are  not  rare  ;  the  greatest  number  of  cases  prob- 
ably occurs  in  the  State  of  Kentucky. 

Varieties. — Of  these  a  sufficient  account  (for  our  purpose)  has 
been  given  in  the  first  part  of  this  book.     (See  Semeiology.) 

Diagnosis.- — Examination  with  the  sound  is  indispensable  to  de- 
termine the  presence  of  a  calculus  in  the  bladder.  The  characters 
of  the  urine  will  aid  in  determining  its  nature.  If  the  urine  be 
decidedly  acid,  the  stone  is  probably  uric  acid  or  oxalate  of  cal- 
cium, or  a  combination  of  both.  If  alkaline  from  fixed  alkali,  it 
is  either  phosphate  or  carbonate  of  calcium  (both  rare).  If  alka- 
line from  volatile  alkali,  whatever  its  nucleus  or  central  part,  the 
surface  must  be  formed  of  the  ammonio-magnesian  phosphate 
with  phosphate  and  carbonate  of  calcium. 

Pain  in  the  bladder  and  in  the  back,  and  pain  or  itching  in  the 
gians  penis,  retraction  of  the  testicle,  and  interruption  in  the  liow 
of  the  urine,  occurring  at  times  suddenly,  are  the  most  prominent 
symptoms  of  stone  in  the  bladder. 

Gravel  consists  of  small  calculous  concretions,  which  may  be 
voided  through  the  urethra.  Pain  in  the  back,  with  chilliness 
followed  by  fever,  commonly  precedes  an  attack,  or  "fit  of  the 
gravel ;  "  to  which  some  persons  are  subject  whenever  they  take 
cold  or  suffer  from  indigestion.  Extreme  pain  may  attend  the 
transit  of  a  small  calculus  through  the  ureter  from  the  kidney  to 
the  bladder. 

This  troublesome  affection  (gravel),  in  the  large  majority  of 
instances,  is  owing  to  undissolved  uric  acid  and  the  urates. 

Treatment  of  Gravel. — Under  the  indication  suggested  by  the 
last-mentioned  fact,  the  dilution  and  alkalization  of  the  urine  are 
called  for.  The  small  calculi  often  irritate  the  bladder  painfully, 
inducing  sometimes  spasmodic  retention  of  urine.  Free  draughts 
of  a  demulcent  liquid,  as  flaxseed  tea,  will  do  good  ;  and  the 
secretion  may  be  made  more  copious,  and  thus  dilute,  and  the 
solution  of  uric  acid  and  its  compounds  promoted,  by  the  admin- 
istration of  spirit  of  nitrous  ether  and  bicarbonate  of  sodium,  in 
tolerably  full  doses,  three  or  four  times  a  day  during  the  attack 
[F.  122].  The  agonizing  pain  from  the  passage  of  a  calculus 
through  the  ureter  will  require  anodyne  treatment,  by  opium,  or 
inhalation  of  ether  or  nitrous  oxide,  and  relaxation  by  the  pro- 
longed warm  bath. 

Prevention. — Any  one  predisposed  to  gravel  (one  sign  of  which 
tendency  is  a  pink  stain  in  the  urinal  left  after  the  urine  has  been 
thrown  out)  should  avoid  highly  animalized  or  otherwise  stimu- 
lating food.  The  urine  may  be  kept  dilute  by  taking  a  tumblerful 
of  water  two  hours  before  dinner,  and  another  at  bedtime.  The 
skin  must  be  kept  open  by  baths,  frictions,  and  sufficiently  warm 
clothing.     Exercise  will  generally  be  beneficial  in  prevention.    If 


DIABETES    INSIPIDUS.  325 

acidity  in  the  urine  be  positi.ve,  synall  doses  of  the  bicarbonate  of 
sodium,  or  of  the  acetate,  citrate,  or  carbonate  of  potassium  may 
be  taken  daily.  Natural  mineral  waters  appear  sometimes  to  do 
good  ;  especially  those  of  tiic  Crab  Orchard  Springs  in  Kentucky 
and  Jk'dford  Springs  of  Pennsylvania  ;  and,  in  Europe,  the  Yiehy, 
Friedrichshalle,  PiiUna,'  Carlsbad,  and  other  waters. 

Treatment  of  Calculus.— Although  the  result  of  much  experi- 
mentation had  been,  until  of  late,  to  turn  over  the  management 
of  stone  to  the  operative  surj^eon,  reason  has  been  given  for 
hoping  for  sometliiug  in  its  relief  without  the  knife  or  lithotrity. 
Dr.  W.  Roberts  has,  in  this,  made  some  promising  observations 
and  experiments. 

Urinary  calculi  may  be,  practically,  divided  into  those  solu- 
ble in  alkalies  and  those  soluble  in  acids.  Of  the  first,  are  uric 
acid  and  its  salts,  and  cystine  ;  of  the  second,  phosphatic  and 
mulberry  calculi.  Solvent  treatment  affords  hope  only  l)y  alkaliz- 
ing the  urine,  in  cases  of  the  former,  by  medicines  taken  by  the 
mouth  ;  and  injecting  acid  solutions  into  the  bladder,  for  direct 
action  upon  mulberry  calculi  and  the  phosphates. 

Very  weak  solutions  of  acetate  or  citrate  of  potassium,  taken 
often,  alkalize  the  urine  most  efficiently,  according  to  Dr.  Roberts's 
experiments.  He  does  not  encourage  the  hope  that  large  or  old 
calculi  can  ever  be  so  dissolved.  Koehler'  affirms  the  solvent 
power  of  boro-citrate  of  rtvujnesiimi  for  uric  acid  calculi.  Its  dose 
is  a  large  teaspoonful  in  half  a  tumblerful  of  water,  thrice  daily. 
Dr.  .J.  C.  Murray'  considers  it  important  for  the  success  of  the 
solvent  practice  that  the  drinking  water  of  the  patient  shall  be 
comparatively  free  from  calcareous  salts.  Dilute  nitric  acid  is 
proposed  for  injection  into  the  bladder  for  the  solution  of  phos- 
phatic calculi,  especially  after  their  being  broken  down  by  the 
litliotrite  ;  and  Sir  B.  Brodie  and  Mr.  Southam  have  carried  this 
procedure  with  some  success  into  practice. 

DIABETES  INSIPIDUS. 

Definition.— Excessive  discharge  of  almost  colorless  urine,  of 
light  weight,  containing  neither  sugar  nor  albumen  ;  with  poly- 
dipsia or  excessive  thirst.     Synonym,  polyuria. 

Causation. — This  is  various,  and  generally  obscure.  More  males 
have  the  aflection  than  females.  It  is  most  common  between  five 
and  thirty  years  of  age.  Blows  on  the  head,  intemperance,  cere- 
bral disease,  and  exposure  to  cold,  or  drinking  cold  fluids  while 
heated,  are  among  the  supposed  causes. 

Pathology. — This,  too,  is  various  and  often  undetermined.  In 
some  instances  degeneracy  or  atrophy  of  the  kidneys  has  been 
found  after  death  ;  in  others,  renal  congestion.  Very  probably 
the  degeneration  may  be  secondary.  Probably  the  immediate 
cause  of  the  excessive  urination  is  dilatation  of  the  capillary 
vessels  of  the  kidneys ;   this  having  its  origin  in  some  remote 

1  PQllna  water,  however,  is  rather  strongly  purgative.  Sir  H.  Thompson  prefers  the 
Friedrichshalle. 

2  Berliner  Wochenschrift,  Nov.  3,  1879. 

3  London  Lancet,  Feb.  1,  1873. 

28 


326      DISEASES   OF   KIDNEYS   AND    BLADDER. 

agency  which  disturbs  the  ganglio-nervous  influence  that  con- 
trols the  circulation. 

Symptoms  and  Course.— Often  beginning  suddenly,  the  amount 
of  water  passed  may  reach  ten  or  twenty  quarts  per  diem.  Thirst 
is  intense,  and  withholding  liquids  does  not  arrest  the  polyuria. 
The  skin  becomes  dry  and  harsh.  Debility  and  emaciation  attend, 
when  the  attack  is  prolonged. 

The  duration  of  the  complaint  varies  from  a  few  days  or  weeks 
to  many  years — or  a  lifetime.  It  is  sometimes  congenital.  An 
intercurrent  attack  of  febrile  or  inflammatory  disease  sometimes 
suspends,  or  even  cures  it. 

Treatment. — This  has  been,  so  far,  tentative  only  ;  no  specific 
is  known  for  it.  Nitrate  of  potassium,  valerian,  ergot,  iron,  alum, 
lime-water,  tannic  and  gallic  acid,  creasote,  and  bromide  of  potas- 
sium are  the  medicines  most  worthy  of  trial.  Blistering  the  nape 
of  the  neck  has  also  been  suggested. 

DIABETES  MELLITTTS. 

Synonym. — Glycosuria. 

Definition. — Excessive  urination,  with  the  presence  of  sugar 
in  the  urine. 

Causation.— Twice  as  many  men  as  women  have  this  disease. 
It  is  most  frequent  among  young  and  middle-aged  adults  ;  the 
mortality  from  it  being  greatest  from  fifteen  to  fifty-five.  It  is 
more  common  in  cities  and  manufacturing  districts  than  in  the 
open  country.  Occasionally  it  is  hereditary.  It  is  common  in 
England,  not  infrequent  in  America,  but  in  Germany  and  Aus- 
tria, rare. 

Exciting  causes  appear  to  be,  exposure  to  cold  and  wet ;  drink- 
ing cold  water  largely  when  heated  ;  excessive  use  of  saccharine 
food  ;  intemperance  ;  violent  emotion ;  febrile  diseases ;  and 
organic  affections  and  injuries  of  the  brain  and  spinal  cord. 
Temporarily,  at  least,  saccharine  urine  accompanies  several 
diseases,  as  chorea,  epilepsy,  hysteria,  delirium  tremens,  insan- 
ity, cholera  (perioid  of  reaction),  pneumonia,  and  rheumatic 
fever  (convalescence).  Inhalation  of  ether  and  that  of  chloro- 
form may  have  the  same  effect.  Milk-sugar  has  been  found  (Hof- 
meister,  Hoppe-Seyler)  in  the  urine  of  puerperal  women. 

Symptoms  and  Course. — Beginning  insidiously,  with  malaise 
and  slight  loss  of  flesh,  urination  becomes  excessive,  with  corre- 
sponding thirst,  and  very  often  bulimia  or  .excessive  appetite ; 
emaciation  is  progressive  ;  the  skin  is  harsh  and  dry  ;  the  tongue 
glazed  and  furrowed,  the  mouth  clammy  ;  ^  the  sexual  and  men- 
tal powers  fail  by  degrees.  Symmetrical  neuralgia  (of  the  sciatic 
or  dental  nerves  on  both  sides)  sometimes  occurs  (Worms ^). 
Lastly,  hectic  fever,  oedema  of  the  limbs,  diarrhoea,  and  often 
all  the  symptoms  of  pulmonary  consumption  terminate  the 
case. 

Complications. — Tuberculization  of  the  lungs  occurs  in  nearly 
half  the  cases  of  diabetes  mellitus  which  last  over  a  year  or  two. 

1  Guenau  de  Mussy  asserts  sourness  of  the  breath  to  be  a  characteristic  of  diabetes. 
*  Archives  Medicales  Beiges,  Feb.,  1881. 


T)T  ARETES     MEI.LITUS.  327 

Inflammations  of  an  asthenic  type  are  common  in  all  the  organs. 
Boils  and  carl)unclcs  arc  very  frequent.  Gangrene  of  the  lower 
extremities  has  been  several  times  observed.  Aml)lyopia  (obscure 
vision)  is  present  in  about  one-fiftii  of  the  cases.  Cataract  gen- 
erally forms  in  cases  of  long  standing ;  but  may  l)e  absent  alto- 
gether in  those  of  less  than  two  years'  duration.  The  (mdosmotic 
theory  of  diabetic  cataract,  suggested  by  tlu;  production  of  opacity 
of  the  lens  in  frogs  by  immersion  in  a  sacchai-ine  solution,  or  by 
injecting  the  same  into  the  cellular  tissue,  is  of  doubtful  applica- 
tion. Objections  to  it  are,  the  temporary  nature  of  the  saccha- 
rine cataract  in  the  frog,  the,  occasional  occui-rence  of  dial)etic 
cataract  in  one  eye  only,  and  the  late  period  at  which  the  symp- 
tom occurs  in  the  disease. 

Morbid  Anatomy  and  Pathology.— Much  remains  to  be  done 
before  the  pathology  of  diabetes  can  be  said  to  be  ascertained. 
In  only  about  half  of  the  cases  some  degree  of  renal  alteration 
is  found.  Pliysiological  facts  and  experiments,  in  regard  to  the 
"glycogenic  function  of  the  liver,"  point  to  that  organ  as  the 
probable  scat  of  the  disorder.  Other  observations,  as  to  the  pro- 
duction of  diabetes  in  animals  by  injuring  the  medulla  oblongata 
or  tiie  base  of  the  brain,  are  also  suggestive.  But,  although  in 
some  instances  autopsic  inspection  has  agreed  with  such  expec- 
tations, in  many  other  cases  it  has  failed  to  confirm  them.  The 
true  theory  of  diabetes  therefore  remains  for  the  future  to  dis- 
cover, or,  at  all  events,  to  complete. 

The  most  plausible  hypothesis,  certainly,  is  that  under  disturbed 
innervation,  the  liver  modifies  its  ordinary  assimilative  process  so 
as  to  confiscate  (to  vise  a  bold  figure)  most  of  the  carbo-hydro- 
genous  material  derived  from  the  alimentary  canal  through  the 
portal  vein,  and  convert  it  into  glucose  or  diabetic  sugar,  which 
is  then  eliminated  by  the  kidneys.' 

Diagnosis. ^The  detection  of  sugar  in  the  urine,  not  tempo- 
rarily, but  for  a  considerable  time,  is  of  itself  sufficient  to  make 
out  the  case.  The  principal  modes  of  testing  saccharine  urine 
have  been  already  given  in  another  part  of  this  book.  (See 
Semeiologtj. ) 

Prognosis.— Recovery  is  not  impossible  in  diabetes ;  but  a  large 
majority  of  cases  end  in  death.  Aniclioratifm—'keeYim^  the  dis- 
ease in  abeyance  — is  often  an  attainable  end.  The  younger  the 
patient  in  whom  the  disoixler  begins,  the  less  the  ultimate  hope. 
In  old  persons  glycosuria  seems  more  often  compatible  with 
tolerable  health  for  a  long  time.     Cases  traced  to  mental  emo- 


1  It  seems  to  be  established  that  a  natural  product  of  the  liver  is  an  amyloid  material 
(hepatin,  liver  dextrin,  glycogen);  whether  Bernard's  view  of  the  normal  destiny  of 
this  being  its  constant  conversion  into  sugar  (and  subsequent  combustion  by  oxidation 
in  the  blood)  be  correct, or  rather  that  of  Pavy,  that  sucli  conversion  is  always  morbid, 
or  post-mortem.  ArlificUtl  glycosuria  maj^  be  produced  in  animals  by  puncturing  the 
tloor  of  the  fourth  ventricle  of  the  t)rain,  impeding  respiration,  thrusting  needles  into 
the  liver,  obstructing  the  abdominal  venous  circulation,  injecting  acid  into  the  veins, 
poisoning  with  strychnia  and  woorara,  and  chloroform  or  ether  inhalation.  Dr. 
McDonnell  has  proposed  the  theory  ihat  "glycogen  "  normally  in  the  liver  combinas 
with  nitrogenous  matter  derived  from  food,  to  make  plastic  material  for  tissue;  and 
that  this  process  is  interrupted  or  arrested  iu  diabetes.  Schitf  caused  glycosuria  by 
merely  inducing  mechanical  liypertemia  of  the  liver.  Excision  of  the  spleen  in  ani- 
mals has  produced  the  same  etfect. 


328       DISEASES    OF    KIDNEYS    AND    BLADDER. 


Fig. 110. 


Sugar  Fungus. 


tion  or  to  injuries  are  somewliat  more  hopeful  than  those  of 
indistinct  origin. 

Amblyopia,  cataract,  and  albuminuria,  as  well  as  phthisical 
symptoms,  mark  the  case  as  incurable.  Considerable  diminution 
of  the  sugar,  or  of  the  water  passed,  is  always  a  favorable  prog- 
nostic.    But  the  diabetic  patient  is  much  more  liable  than  others 

to  those  inflammatory  compli- 
cations which,  on  slight  expos- 
ure, may  hasten  the  termina- 
tion of  life. 

Treatmeiit. — No  direct  con- 
trol over  the  sugar-forming 
process  in  the  body  has  yet 
been  obtainable  by  medicine. 
But,  although  it  would  seem 
that  simply  diminishing  the 
formation  of  sugar  by  with- 
holding material  for  it  ought 
not  to  be  expected  to  do  much 
good,  it  does  prove  beneficial. 
At  the  same  time  Dr.  Harley 
has  shown  that  the  weight  of 
the  patient^  not  the  amount  of 
sugar  passed,  is  the  true  test 
of  improvement  or  the  reverse. 
The  most  generally  approved 
measure  in  the  management  of 
diabetes,  is  the  prohibition  of  sugar  and  starch,  and  of  everything 
which  can  yield  them,  as  food.  Bread,  except  bran  bread,  which 
contains  but  little  starch,  potatoes,  and  nearly  all  vegetables  and 
fruits,  must  be  excluded.  The  safe  exceptions  are  the  cabbage, 
broccoli,  onions,  spinach,  celery,  and  lettuce.  Of  animal  diet, 
milk  and  liver  are  forbidden  articles.  Donkin's  treatment,  how- 
ever, with  skimmed  milk,  is  reasonable  in  diabetes,  and  may 
answer  very  well.  All  meats,  eggs  and  butter,  and  jellies,  are 
allowable.  Gluten  bread  is  made  in  France,  on  Bouchardat's  plan, 
without  starch,  inflated  by  machinery  with  carbonic  acid  or  com- 
pressed air.  Tea  or  coffee  may  be  sweetened  with  glycerin  (chem- 
ically pure,  as  Bower's  or  Price's).  Spirits,  wines,  and  beer  should 
be  avoided  unless  called  for  by  very  positive  weakness  ;  if  that 
exist,  the  least  saccharine  should  be  preferred,  as  sherry,  claret, 
or  whisky,  in  minimum  quantities.  There  is  no  advantage  in 
restricting  the  amount  of  water  taken  to  quench  thirst.  Variety 
of  diet  of  course,  within  the  prescribed  limits,  is  important  to 
prevent  disgust  and  loss  of  appetite. 

Of  medicines,  none  have  been  yet  shown  to  do  much  service  in 
checking  the  disease.  The  most  positive  influence  in  diminishing 
the  diuresis  and  secretion  of  sugar  (Pavy),  belongs  to  opium  ;  but 
this  does  not  appear  to  interfere  much  with  the  progress  of  the 
disease.  Dr.  Buttura  reports  the  cure  of  a  case  by  a  seton  in  the 
neck.  Sir  T.  Watson  speaks  well  of  the  relief  aflbrded  by  the 
hot-air  hath.  Various  drugs  have  been  tried,  and  lauded  greatly 
by  different  users  ;  but  their  effects  will  not  bear  scrutiny  without 


HYDRONEPHROSIS.  329 

disappointment.  Anionu;  tboin  tin;  most  prominent  are  alkalies, 
yeast,  rennet,  pepsin,  iron,  quinine,  crcasote,  earbolicacid,'  alum, 
iodine,  nitric  aeid,  turpentine,  citrate  of  sodium  (half  a  drachm 
to  a  drachm  daily),  arsenic,  crgat,  j<ihormi<li,  and  the  inhalation 
of  oxygen.  Even  free  ingestion  of  awjar  has  been  fairly  experi- 
mented with.  Dr.  Wadham  found,  in  one  case,  that  using  brmd 
as  food  increased  the  sugar  in  the  urine,  while  white  sugar  did  not. 
No  cure  resulted,  however,  from  the  use  of  sugar.  The  remedy  for 
diabetes  remains  to  be  discovered.  Cod-liver  oil  and  other  anfo- 
leptics  arc  indicated,  to  counteract  the  tendency  to  debility  and 
emaciation.  Kubbing  with  oil  (Inman)  may  perhaps  do  good  in 
the  same  way.  Drs.  Donkin  and  Greenhow  report  recoveries 
upon  an  exclusive  diet  of  skimmed  milk.'  Professors  Cantani 
and  Primavera,''  of  Naples,  assert  great  success  under  an  exclu- 
sive meat  diet,  with  the  administration,  at  each  meal,  of  3ij-iv 
of  lactic  acid,  in  water  fgyj,  and  also  fgss  of  alcohol  in  water 
f^yj.  The  purpose  of  the  lactic  acid  and  alcoliol  is  to  substitute 
the  saccharine  and  fiirinaceous  constituents  of  food,  without  any 
material  for  the  formation  of  sugar,  Schaetzke '  treated  three 
cases  successfully  with  salicylic  acid.  M.  Lefort  obtained  improve- 
ment in  a  case  by  the  constant  galvanic  current :  one  pole  being 
applied  to  the  back  of  the  neck,  and  the  other  over  the  region 
of  the  liver  {Gazette  M-dicale  de  Faris^  April  13,  1872). 

HYDRONEPHROSIS. 

Dafinition. — Renal  dropsy ;  dilatation  of  the  kidney  from  obstruc- 
tion of  the  ureter. 

Causation. — Quite  a  number  of  the  cases  recorded  have  been 
congenital,  from  anatomical  malformations.  Calculus  in  the 
ureter  is  the  most  frequent  post-natal  cause  ;  but  other  mechani- 
cal obstructions  from  pressure  may  occur. 

Diagnosis.  —Intumescence  of  the  abdomen,  usually  upon  one 
side,  in  the  hypochondriac,  umbilical,  and  iliac  regions,  with  a  soft 
undulating  feel,  an  outline  often  lobulated,  and  fluctuation,  as 
well  as  duluess  upon  percussion,  can,  in  the  male  at  least,  only 
indicate  either  hydro-  or  pyonephrosis.  The  symptoms  may  be 
almost  null  if  only  one  kidney  be  affected.  When  both  are  so, 
urremia  finally  results.  The  tumor  is  commonly  quite  painless, 
and  not  tender  upon  pressure.  This  affection  is,  however,  quite 
rare.  It  may  be  fatal  by  uraemia,  or  by  bursting  of  the  sac  into 
the  abdomen  ;  but  it  has  in  a  number  of  cases  existed  for  many 
years. 

Treatment. — Manipulation^  kneading  gently,  day  after  day,  has 
sometimes  succeeded  in  dissipating  the  renal  distension.  Nothing 
else  should  be  attempted,  unless  life  be  endangered  by  the  pressure 
of  the  tumor  or  by  urfemia.  If  it  be  so,  tapping  is  justifiable  ;  and 
it  has  been  repeatedly  performed  with  success.  Preliminary 
explorations  may  be  made  with  the  grooved  needle,  hypodermic 
syringe,  or  aspirator. 

1  Ernstein  and  Muller,  Berlin  Klin.  Woch.,  Dec.  8, 1873. 

2  Brit.  Med.  Journal,  June  7, 1873. 

3  New  York  Med.  Rycord,  May  1,  1873. 
■•Berliner  Klin.  Wochenschrii't,  June2,  1879, 

28* 


330      DISEASES   OF  KIDNEYS   AND   BLADDER. 

PYONEPHROSIS. 

This  differs  from  the  last-named  affection  in  the  production, 
under  similar  circumstances,  with  more  or  less  inflammation,  of 
suppuration  of  the  kidney.  The  sj'mptoms  are  therefore  more 
active,  and  the  prognosis  more  grave.  Rupture  of  the  suppu- 
rating kidney  into  the  colon,  duodenum,  or  peritoneal  cavity,  is 
common,  and  is  often  fatal.  Renal  abscess  may  occur  also  from 
"  purulent  infection  "  and  from  embolism.  Such  an  abscess  may 
find  escape  for  its  contents  externally  ;  any  appearance  of  such 
a  tendency  should  be  encouraged  by  poulticing,  and,  in  fit  cases, 
by  aspiration,  incision,  and  evacuation. 

Perinephritic  abscess  has  been  described  as  a  rare  affection  by 
Rayer,  Trousseau,  Bowditch,^  and  others.  Its  signs  are  pain  and 
swelling  in  the  lumbar  region,  chills  and  fever,  emaciation  and 
debility,  with  some  lameness  of  the  lower  limb  on  the  side 
affected.  Pleuritic  or  pulmonary  complication  may  occur.  In 
three  cases  treated  by  Dr.  Bowditch,  recovery  took  place  after 
incision  for  the  discharge  of  pus,  in  a  few  weeks  or  months.  Dr. 
F.  D.  Lente,  of  Cold  Spring,  N.  Y.,  has  also  succeeded  in  obtain- 
ing recovery,  after  cutting  down  upon  the  kidney  througli  the 
quadratiis  lumborum  muscle,  and  effecting  drainage  by  means  of 
a  tube  or  canula. 

CANCER  OF  THE  KIDNEY. 

Primary  cancer  of  the  kidney  is,  though  rare  at  any  age,  most 
frequent  in  early  childhood.  Of  adults,  males  have  been  .the 
most  numerous  subjects  of  it.  Secondary  renal  cancer  may 
attend  any  case  of  the  cancerous  cachexia,  without  materially 
modifying  its  history. 

The  kind  of  cancer  affecting  the  kidney  is  nearly  always  the 
encephaloid  ;  called,  when  highly  vascular,  fungus  hematodes. 
It  always  begins  in  the  cortical  substance.  The  tumor  is  gen- 
erally large,  and  sometimes  enormous  ;  reaching  in  one  case 
(Roberts)  31  pounds.  It  is  exceedingly  rare  for  both  kidneys 
to  be  affected. 

Diagnosis. — An  abdominal  tumor,  with  copious  hsematuria 
repeated  at  irregular  intervals,  is  almost  certain  to  be  cancer 
of  the  kidney. 

Beginning  between  the  ribs  and  crest  of  the  ilium  on  one  side, 
the  tumor  grows  forwards,  upwards,  and  downwards,  so  as  to  fill 
in  some  cases  the  whole  belly.  The  colon  in  this,  as  in  all  renal 
tumors,  lies  in  front  of  it ;  as  does  also  sometimes  a  part  of  the 
small  intestine.  Except  over  the  intestine,  percussion-resonance 
is  dull. 

The  swelling  is  smooth  or  irregularly  lobulated  ;  now  and  then 
a  sort  of  fluctuation,  and  in  one  instance  pulsation,  have  been 
observed  in  it.     It  is  fixed  in  its  position. 

Bloody  urine,  usually  profuse  hemorrhage,  is  present  in  about 
half  the  cases.  N"o  other  tumor  has  such  hemorrhage  attending 
it:'^  its  occurrence  is  therefore  pathognomonic.     The  discovery 

1  Boston  Med.  and  Surg.  Journal,  July,  1868. 

2  Roberts  mentions  one  case  of  great  enlargement  of  the  spleen  with  hsematuria. 


AMYLOID    KIDNEY.  881 

of  cancer-cells  in  the  urine  l)y  the  microscope  is  of  course  still 
more  positive ;  but  this  siij;n  is  very  often  absent,  and  the  cells 
are  not  at  all  easy  of  identilication  when  they  occur. 

Pain  mostly,  but  not  always,  attends  cancer  of  the  kidney;  it  is 
sometimes  of  great  sevei'ity,  shooting  down  the  ureter  to  the 
thigh.  Tenderness  on  pressure  seldom  exists.  Variable  symp- 
toms are  those  of  disorder  of  the  stomach  and  bowels.  Emaci- 
ation and  anasarca  show  the  exhaustion  which  precedes  death. 

The  duration  of  cancer  of  the  kidney  in  children  averages 
seven  or  eight  months;  in  adults  over  two  years.  This  is  a 
longer  period  than  that  of  any  other  visceral  cancer. 

In  treatment,  as  with  other  malignant  diseases  incapable  of 
cure,  the  judicious  management  of  regimen  and  anodynes  is  all 
that  is  possible  ;  except  that  extirpation  of  the  kidney  has,  of  late 
years,  been  several  times  successfully  performed.' 

TUBERCLE  OF  THE  KIDNEY. 

This  may  be  either  primary  or  secondary.  Of  all  tuberculous 
subjects,  the  kidney  is  found  to  contain  such  deposits  in  only  from 
five  to  six  per  cent.  Amono-  tuberculous  children,  in  from  fifteen 
to  sixteen  per  cent.    Most  of  these,  however,  wei-e  secondary  cases. 

The  symptoms  of  primary  renal  tuberculization  are,  dull  lum- 
bar pain,  frequent  micturition  (the  urine  being  at  first  turbid  or 
slightly  bloody,  afterwards  purulent),  emaciation,  and  hectic 
fever.  Almost  always  other  organs,  especially  the  lungs,  be- 
come also  tuberculous;  merging  the  case  into  one  of  complicated 
phthisis.  The  bowels  are  very  frequently  implicated.  Death 
occurs  mostly  from  exhaustion.  If  both  kidneys  are  afiected,  it 
may  take  place  from  uraemia. 

The  duration  of  the  affection  varies  from  a  few  months  to  two 
or  three  years. 

Diagnosis. — Only  after  softening  of  the  tubercle  can  it  be  pos- 
itively proved  to  exist.  Then  the  abundantly  purulent  urine  is 
found  upon  microscopic  inspection  to  contain  also  "granular 
debris,  sometimes  with  tuberculous  matter  (insoluble  in  acetic 
acid),  shreds  of  connective  tissue,  and  beautiful  meshes  of  elastic 
fibres  from  the  cast-oft'  patches  of  disintegrated  mucous  mem- 
brane." Great  debility  and  emaciation,  with  hectic  fever, 
confirm  these  signs.  The  absence  of  tumor  and  of  htematuria 
distinguishes  renal  tuberculization  from  cancer. 

Treatment. — Here,  again,  we  must  confess  the  deficiency  of  our 
present  therapeutics.  Indications  exist,  essentially  the  "same  as 
in  phthisis  pulmonalis,  to  the  consideration  of  which  we  may 
refer  the  reader. 

AMYLOID   KIDNEY. 

Under  a  constitutional  tendency,  congenital  or  acquired,  result- 
ing from  syphilis,  tubercular  diathesis,  long-continued  suppura- 
tion, or  some  other  source  of  degeneration,  this  change  may 
occur  in  the  kidney,  though  less  often  than  in  the  livei\     Its 

1  Byford,  of  Chicago,  and  Couper,  of  London,  performed  this  operation  successfully 
during  the  year  1880.  See  Boston  Med.  and  Surg.  Journal,  Sept.  23,  1880,  and  Arner. 
Journal  of  Med.  Sciences,  January,  1881. 


832      DISEASES   OF  KIDNEYS   AND   BLADDER. 

signs,  as  distinguished  from  other  forms  of  chronic  renal  disease, 
are  not  mifrequently  obscure. 

Dropsy,  if  present,  attains  only  to  a  moderate  degree ;  it  is 
especially  apt  to  take  the  form  of  oedema  of  the  lower  extremities 
and  ascites.  Vomiting  and  diarrhoea  occur  late  in  the  progress 
of  the  disease.  The  amount  of  urine  passed  may  be  normal, 
or  even  more  than  that  secreted  in  health  ;  in  some  cases  it  is 
reduced.     In  an  advanced  case  albuminuria  may  be  detected. 

Unless  through  the  cure  of  constitutional  syphilis  by  appro- 
priate medication,  we  have  little  to  hope  from  the  treatment  of 
this  affection.  It  is  apt  to  be  onlj'  a  secondary  part  of  a  general 
tendency  to  decline  in  the  system,  manifested"  in  other  organs  as 
well  as  in  the  kidneys.  It  has  been  incidentally  alluded  to 
already  as  one  of  the  varieties  of  renal  alteration  classed  to- 
gether under  the  general  head  of  BrighVs  disease. 

After  death,  this  form  of  degeneration  may  be  recognized  by 
the  waxy  aspect,  translucency,  and  doughy  elasticity  of  the 
.affected  portions  of  the  kidney.  Very  often  the  whole  of  one 
or  both  kidneys  may  be  thus  altered.  When  complicated  with 
other  changes,  the  amyloid  material  may  be  clearly  distinguished 
by  two  chemical  reactions.  1.  Wash  the  kidney  thoroughly  from 
blood,  and  then  pour  over  it,  or  paint  upon  it  with  a  brush,  a 
watery  solution  of  iodine.  The  am3'loid  parts  will  soon  become 
violet-red,  or  of  a  mahogany  color.  A  few  drops  of  sulphuric 
acid  will  convert  this  to  a  blue  tint,  2.  Methyl-green  (methyl- 
aniline)  will  cause  a  decidedly  red-violet  reaction  with  amyloid 
matter ;  while  the  same  test  will  stain  the  healthy  kidney  with 
a  bluish  color. 

Cirrhosis  of  the  kidney  is  another  of  the  varieties  of  degen- 
erative change,  analogous  to  cirrhosis  of  the  liver,  whose  clinical 
history  is  with  much  difficulty  separable  from  that  of  other  affec- 
tions which,  in  practice,  are  apt  to  be  included  under  Bright 's 
disease. 

HYDATIDS   OF   THE  KIDNEY. 

These  are  more  rare  than  hydatids  in  the  liver  or  lungs ;  but 
more  frequent  than  in  other  parts  of  the  body.^  The  left  kidney 
is  most  often  affected. 

In  a  majority  of  cases  the  cyst  formed  by  the  echinococcus  opens 
into  the  pelvis  of  the  kidney.  The  hydatids  then,  in  part  or 
vrholly,  are  discharged  by  the  urethra.  They  may,  however, 
also,  or  instead,  burst  into  the  stomach,  intestines,  or  lungs. 

If  no  such  vent  occurs,  a  tumor  is  formed  in  the  side  (with  the 
colon  always  in  front  of  it)  which  has  a  more  or  less  distinct  fluc- 
tuation, and  sometimes  the  "hydatid  fremitus,"  or  vibration  to 
the  touch. 

The  discharge  of  the  contents  of  the  cyst  allows  the  discovery, 
in  some  cases,  of  entire  vesicles ;  in  others,  of  a  detritus,  in  which 
the  microscope  detects  echinococcus-hooks,  laminated  shreds,  and 
oil  particles. 

1  According  to  Davaine,  the  order  of  relative  frequency  is  as  follows:  Liver,  lungs, 
kidneys,  pelvis,  brain,  bones,  parietes  of  the  body,  heart,  and  orbit  of  the  eye. 


CYKTITI.S.  888 

This  (liscliari^o  is  apt  to  l)o  recurrent  or  paroxysnial  ;  at  inter- 
vals varyiii?;  from  a  Ihw  \vee!<s  to  one  or  more  years.  Before?  it 
occurs,  chills,  nausea,  liiccou^h,  and  colicky  pains  often  exist, 
relieved  by  the  passage  of  the  vesicles.  These,  while  in  the  blad- 
der, may  cause  pain,  irritation,  and  retention  of  urine. 

After  every  such  an  escape  the  size  of  the  tumor  may  be  lessened 
for  a  time.  A  vesicle  detained  in  the  ureter  may,  by  obstruction, 
induce  a  hi/dronephrosis,  adding  to  the  hydatid  tumescence. 

Prognosis. — This  is  more  favorable  tlian  in  any  other  seat  of 
hydatids,  except  the  uterus,  because  of  the  comparative  flicility 
of  their  evacuation.  "When,  however,  no  escape  by  the  kidney 
and  ureter  is  effected,  the  tumor  may  become  so  large  as  to 
encroach  seriously  upon  other  parts,  or  the  cyst  may  suppurate 
(pyonephrosis)  and  form  a  lai'gc  and  dangerous  abscess. 

Treatment. — Oil  of  turpentine,  iodide  of  potassium,  chlorate  and 
nitrate  of  potassium,  taraxacum,  and  other  medicines  have  been 
asserted  ])y  different  observers  to  promote  the  death  and  discharge 
of  echinococci.  Whether  the  ''post  hoc"  was  "propter  hoc  "  in 
these  cases,  larger  experience  (which  ought  always  to  be  recorded) 
will  show.  Electro-puncture  has  been  tried  for  the  same  end ; 
but  without  proof  of  success. 

■  Hydatid  colic  (passage  of  vesicles  through  the  ureter)  may  be 
treated  like  that  froni"  calculus,  by  the  warm  bath  and  opium. 
Irritation  of  the  bladder,  or  obstruction  causing  retention  of 
urine,  will  require  rest,  demulcent  drinks  (flaxseed  infusion),  and 
sometimes  the  catheter.  Even  in  the  urethra  the  escape  of  the 
vesicles  may  be  obstructed,  and  sometimes  may  require  to  be 
aided  by  pressure  for  their  dislodgment. 

A  closed  renal  hydatid  tumor,  when  clearly  diagnosticated,  and 
itself  endangering  life,  may  be  (after  exploration  by  the  needle- 
trocar)  puncl;uretl,  especially  if  it  project  behind.  When  in  front, 
Recamier's  plan  is  preferred  by  some  surgeons,  of  applying  caus- 
tic potassa  repeatedly  to  cause  adhesion  of  the  peritoneum  to  the 
sac,  before  making  the  incision.  Safer  than  this,  and  in  at  least 
one  case  successful,  is  repeated  puncturing  with  the  needle-trocar 
at  intervals  of  a  few  days.  Nephrectomy  (extirpation  of  the 
kidney)  has  sometimes  been  performed  for  cystic  disease.^ 

CYSTITIS. 

Definition. — Infiammation  of  the  bladder. 

Varieties. — Acute  and  chronic ;  idiopathic,  traumatic,  sec- 
ondary. 

Causation. — Blows  or  other  injuries  ;  the  presence  of  gravel, 
or  calculus,  or  hydatid  vesicles  from  the  kidney ;  irritating  diu- 
retics, or  decomposing  urine  retained  by  stricture,  may  induce 
acute  cystitis.  The  continuation  or  frequent  repetition  of  these 
causes  produces  "  chronic  intlammation  of  the  bladder."' 

Symptoms :  Acute  Cystitis. — Pain  in  the  vesical  region ;  frequent 
desire  to  pass  water,  with  burning  in  the  urethra,  and  tenesmus, 
or  disposition  to  bear  down  or  strain.     There  is  fever,  alternating 

1  Couper,  1880;  see  Phila.  Med.  Times,  Jan.  29,  188],  p.  283. 


334      DISEASES   OF    KIDNEYS    AND    BLADDER. 

with  chills.  The  bladder  may  sometimes  be  felt  as  a  small  round 
swelling,  sensitive  upon  pressure.  In  bad  cases  there  are  nausea, 
anxiety,  delirium,  and  cold  perspirations  ;  the  scantily  passed 
urine  becomes  purulent  and  bloody,  alkaline  and  fetid. 

Chronic  Cystitis  has  usually  much  less  severity  of  symptoms ; 
but  it  may  be  very  distressing,  from  the  tenderness  and  irritability 
of  the  bladder,  and  the  frequent  disposition  to  urinate,  with 
dysuria.     The  urine  is  either  mucous  or  muco-purulent. 

Treatment. — Acute  cystitis,  with  perfect  rest,  may  need  leech- 
ing or  cupping  above  the  pubes  or  (leeching)  at  the  perineum. 
As  a  laxative,  castor  oil  is  apt  to  be  the  best.  Warm  hip-baths 
will  be  very  soothing.  Where  heat  is  great,  however,  small  pieces 
of  ice  introduced  into  the  rectum  will  give  more  relief.  Flaxseed 
tea  may  be  taken  freely.  Opium,  chloral,  hyoscyamus,  or  bella- 
donna may  be  called  for  by  great  pain  or  nervous  irritability. 
Opium  or  belladonna  suppositories  [F.  124,  125],  or  laudanum 
enemata,  will  answer  best  if  anodynes  have  to  be  repeated  often. 
A  remedy  reported  well  of  by  Dufau,  Vaulthier^  and  Busey,^  is 
the  stigma  of  maize  (Indian  corn),  in  fluidrachm  doses  of  the  fluid 
extract.  It  appears  to  be  an  effective  diuretic.  Dr.  Garnett,* 
of  Washington,  asserts  that  the  seed  of  hroom-corn  (sorghum 
vulgare),  in  decoction,  has  similar  efficacy.  In  chronic  cystitis 
local  depletion  is  much  less  likely  to  do  good.  The  other  meas- 
ures named  may  be  suitable  from  time  to  time  ;  also  injections 
of  lime-water  and  glycerin,  or  weak  solution  of  nitrate  of  silver, 
or  of  sulphate  of  copper,  or  aceta  te  of  lead,  in  water  or  in  glycerin, 
may  be  serviceable.  Damiana  Tumera,  of  Mexico,  is  said  to  have 
a  beneficial  tonic  effect  upon  the  bladder.  Catlieterism  may  at 
times  be  indispensable,  both  in  acute  and  chronic  cystitis ;  but  it 
should  be  avoided  if  possible,  on  account  of  the  mechanical  irri- 
tation of  the  instrument.  Even  in  washing  out  the  bladder,  care 
must  be  taken,  as  harm  may  be  done  by  the  forcible  introduction 
of  too  large  an  amount  of  fluid  ;  or,  still  more,  by  too  strong  solu- 
tions of  stimulating  substances. 

RETENTION  OF  UEINE. 

Synonyms. — Strangury.  Dysuria^  Ischuria.  Although  the  me- 
cJiayiical  or  surgical  causes  and  history  of  difficult  or  arrested  urina- 
tion do  not  belong  to  this  work,  it  will  be  proper  to  speak  briefly 
of  its  occasional  importance,  as  a  sympton  in  the  course  of  diseases 
which  every  medical  practitioner  must  meet. 

Retention  of  urine  happens  either  from  mechanical  obstruction, 
from  spasm,  with  or  without  inflammatory  congestion  at  the  neck 
of  the  bladder,  or  from  vesical  atony  or  paralysis.  The  first 
occurs  in  cases  of  stricture,  calculus,  etc. ;  the  second  under  the 
influence  of  cantharides  or  turpentine,  or  in  cystitis  from  any 
cause ;  the  third,  in  typhus,  typhoid,  and  other  low  fevers  and 
states  of  debility. 

It  is  very  easy  in  all  but  the  last-named  eases  to  distinguish 

1  Archives  Med.  Beiges,  Aug.,  1881. 

2  N.  y.  Med.  Record,  June  4,  1881,  p.  619. 

s  Amer.  Journal  of  Med.  Sciences,  July,  1881,  p.  164. 


TNFI.AMM  ATION     OF    THE    BRAIN.  335 

retention  from  suppression  of  urine.  In  low  fevers,  etc.,  it  is  not 
at  all  dirticult  to  make  this  diagnosis  upon  cxarnination ;  without 
this,  the  retention  maj'  l)e  overlooked.  The  practitioner  must 
never  forget  to  ascertain  whetiier  his  patient  passes  water  or  not. 
In  all  serious  diseases,  indeed,  its  regular  inspection  is  important. 

In  the  semi-paralytic  retention  of  low  states,  catheterism  is 
generally  required  ;  and,  when  disteuUon  anil  dnlness  upon  pcrcMs- 
sion  atiorc  the  piOn's,  with  ahsencc  of  urinary  discharge  for  twelve 
or  twenty-four  hours,  or  only  dribbling,  mark  the  case,  the  instru- 
ment should  be  used  without  delay,  and  repeatedly ;  at  least  once 
daily  in  most  instances. 

Spasmodic  retention  of  urine,  or  strangury,  with  or  without  the 
concomitant  existence  of  stricture  or  gravel,  may  demand  other 
means  of  relief  instead  of  or  besides  the  catheter.  The  warm 
hip-bath,  prolonged  for  half  an  hour,  is  one  of  the  best  measures. 
Cloths  wrung  out  of  hot  water  applied  to  the  perineum  and  over 
the  pubes  may  assist.  Leeches  to  the  perineum,  when  there  is 
local  tenderness,  will  often  promote  relaxation  of  the  part. 
Laudanum  enemata,  and  opium  [F.  124,  125]  or  belladonna 
suppositories,  will  sometimes  relieve  when  other  measures  fail. 
Anaesthetic  inhalations  might  be  resorted  to  in  an  extreme  case. 
Hypodermic  injection  of  morphia  has  been  used  to  give  relief. 

ENURESIS. 

Definition. — Incontinence  of  urine.  Except  from  paralysis  or 
some  local  lesion,  this  troublesome  affection  is  not  apt  to  occur  in 
the  adult.     In  children  it  is  common,  especially  at  night. 

Treatment. — Withholding  fluids  for  some  hours  before  bed- 
time, unless  in  very  small  quantities,  and  taking  the  child  up  to 
urinate  after  two  or  three  hours  of  sleep,  will  generally  prevent 
enuresis.  Of  medicines,  those  most  employed  (with  variable 
success)  are  belladonna,  benzoic  acid  [F.  126],  and  tincture  of 
chloride  of  iron.  Chloral^  has  been  found  useful,  and  so  have 
erejot  and  iodide  of  iron.'^  Corrigan^  recommends  sealing  up  the 
prepuce  at  night  with  collodion. 

Moral  impressions,  acting  upon  the  child's  sense  of  shame  or 
wrong,  are  only  proper  to  be  made  use  of  with  great  care  and 
discretion ;  but  sometimes  they  have  much  power. 

AFFECTIONS  OF  THE  BEAIN  AND  NERVOUS 

SYSTEM. 

INFLAMMATION  OF  THE  BRAIN. 

Synonjnns. — Encephalitis,  Phrenitis,  Meningitis,  Cerebritis.  The 
last  two  are  not,  of  course,  technically  identical ;  but  they  are 
not  clinically  separable.  Inflammation  of  the  membrane  derives 
its  importance  from  the  implication  of  the  brain. 

Varieties. — Simple  and  scrofulous  encephalitis  or  meningo-cere- 
britis. 

1  Bradbury.  Brit.  Med.  Journal,  Feb.  4,  1871. 
2Barolay,  Med.  Times  and  Gazette,  Dec.  17,  1870. 
3  Dublin  Quart.  Journal  of  Med.  Science,  Feb.,  1870. 


336    DISEASES    OF    BRAIN    AND    NERVOUS   SYSTEM. 

Simple  Mening-o-cerebritis  (meningitis).   S3nnptoms.— Intense 

headache,  redness  of  face  and  eyes,  an  excited  look,  dizziness, 
roaring  in  the  ears,  extreme  sensitiveness  to  light  and  sound, 
restlessness,  wakefulness,  wild  delirium.  Vomiting  is  common  ; 
the  bowels  are  usually  costive.  Some  dangerous  cases  exhibit  but 
little  mental  excitement  even  at  the  beginning,  and  very  little 
fever ;  dulness  of  mind,  deepening  into  apathy,  with  vomiting, 
and  general  prostration,  being  the  symptoms.  Late  in  the  attack 
in  adults,  at  any  period  in  children,  convulsions  may  occur. 
Eigidity  of  the  muscles  is  frequent  in  bad  cases ;  paralysis  often 
follows  convulsions. 

Stagces. — These  are  generally  described  (since  Whytt)  as  three. 
1st.  That  of  active  congestion  and  inflammation  ;  with  hot  skin, 
hard,  rapid,  full  regular  pulse,  morbid  sensitiveness  to  light  and 
sound,  headache,  and  delirium.  2d,  That  of  commencing  effusion 
and  cerebral  oppression  ;  with  more  moderate  heat  of  the  surface, 
stupor,  and  slow,  or  irregular  pulse.  3d.  That  of  cerebral  disa- 
bility or  disorganization ;  with  unconsciousness,  convulsions, 
muscular  rigidity  or  paralysis,  and  rapid,  feeble  pulse.  This 
precise  succession  of  stages,  however,  does  not  invariably  occur. 

Morbid  Anatomy. — Except  in  traumatic  cases,  the  dura  mater 
rarely  takes  part  in  the  lesions  of  encephalitis.  Eather  minute 
hypersemie  injection  is  found  here  and  there  in  the  arachnoid  ^ 
membrane  ;  sometimes  opacity  and  thickening  occur,  with  adhe- 
sions. In  the  pia  mater,  generally  with  considerable  increase  of 
redness,  serum  has  been  effused  ;  or  even  pus.  The  pia  mater 
adheres  firmly  to  the  brain.  The  ventricles  contain  more  serum 
than  usual,  sometimes  several  ounces.  In  some  cases  it  is  turbid, 
flocculent,  or  purulent.  The  brain  itself  is  most  frequently  affect- 
ed with  redness  in  the  convolutions,  and  dots  of  blood  in  the 
medullary  portion ;  also,  with  softening  in  the  gray  or  white 
substance,  or  in  both. 

Diagnosis. — The  distinctions  between  simple  and  tuberculous  or 
scrofulous  meningitis  or  encephalitis  will  be  considered  presently. 
Typhoid  fever,  delirium  tremens,  and  acute  mania  may  be  con- 
founded with  or  mistaken  for  inflammation  of  the  brain. 

Typhoid  fever  does  not  generally  have  vomiting,'^  long-continued 
headache,  or  morbid  sensibility  to  light  among  its  symptoms ; 
while  tympanites,  diaiThosa,  bronchitic  cough,  etc.  ,make  it  known. 
In  delirium  tremens,  the  origin  of  the  aflection  in  alcoholic  excess, 
the  usually  horrible  illusions,  tremor,  and  insomnia,  without  head- 
ache, are  characteristic.  Acute  mania  is  almost  or  quite  without 
fever ;  often  without  headache  ;  and  the  muscular  strength  is 
generally  little  impaired  ;  vomiting,  also,  is  absent. 

Subacute  or  chronic  encephalitis,  now  and  then  met  with, 
presents  greater  difficulty  in  distinguishing  it  from  mania.  Indeed, 
the  best  authorities  in  psycho-pathology  (study  of  mental  disease) 
state  that  cerebral  hyperemia  and  inflammation  bear  a  not  unim- 

1  The  omission  of  the  arachnoid  as  a  definite  membrane  in  the  anatomical  descrip- 
tion of  tlie  brain,  as  practised  by  some  recent  authors,  appears  to  me  an  arbitrary- 
measure,  not  justified  by  facts. 

2  In  infantile  typhoid  fever,  vomiting  occurs  more  often  than  in  adults. 


INFLAMMATION     OP    THE     BRAIN.  337 

portant  part  in  the  pathol(^y  of  insanity.  (See  Winslow  on  the 
Brain  and  Mind.) 

Children  aflbvd  not  unfrequcnt  instances  of  another  question  in 
diagnosis ;  how  far  siinqAonts  alfecting  the  l)rain  may  or  may  not 
depend  upon  the  stovmch  for  their  causation.  "Gastric  fever" 
and  "infantile  remittent"  arc  phrases  formerly  applied  often  to 
attacks  occurring  in  childhood  or  infancy  ;  in  which  with  fever, 
indigestion,  and  vomiting,  there  is  delirium,  stupor,  or  apathy, 
with  or  without  convulsions.  In  such  cases,  the  heat  of  head  and 
fulness  of  the  carotid  and  temporal  arteries  are  less,  the  gastric 
disorder,  fur  of  tongue,  etc.,  greater  than  in  cere])ral  inflamma- 
tion. Those  not  ephemeral  are  mostly  cases  of  typhoid  fever. 
Cholera  infantum  is  often  attended  by  brain  symptoms ;  but  its 
other  features,  the  time  of  year,  and  locality  (in  a  large  city  almost 
always)  are  distinctive. 

The  ophthcdmoscojje,  under  the  investigations  of  Bouchut,  All- 
butt,  Ilughlings  Jackson,  Pagenstecker,  and  others,  has  now 
obtained  a  recognized  place  in  aiding  the  diagnosis  of  aflections 
of  the  brain,  w^hether  inflammatory  or  atrophic  and  degenerative. 
"Choked  disk,"  i.  c,  active  congestion  of  that  portion  of  the 
retina  around  the  entrance  of  the  optic  nerve,  appears  to  be 
mostly  indicative  of  cerebral  (or  at  least  intra-cranial)  inflam- 
mation.^ 

Prognosis. — Simple  encephalitis,  under  good  treatment,  is  not 
always  fatal,  but  a  majority  of  cases  end  in  death.  I  remember 
a  considerable  number  of  recoveries  ;  four  from  extremely  severe 
symptoms.  In  one  case,  that  of  a  girl  ten  years  of  age,  a  con- 
vulsion immediately  preceded  convalescence. 

Causation. — Between  fifteen  and  forty-five  is  the  age  most 
subject  to  this  disease.  Males  are  more  liable  than  females  to  it. 
Hot  climates  predispose  to  it ;  and  so  does  intemperate  living. 
Exciting  causes  are  blows  or  falls  upon  the  head,  exposure  to  the 
sun,  violent  or  prolonged  mental  excitement,  erysipelas  of  the 
head,  scarlet  fever,  metastasis  of  rheumatic  or  gouty  inflamma- 
tion, repulsion  of  eruptions  upon  the  skin,  suppression  of  accus- 
tomed discharges.  Extension  of  inflammation  from  the  ear 
(otitis)  to  the  brain  is  a  possibilit}^  important  not  to  be  overlooked. 
Cerebral  thrombosis  may  sometimes  result  from  the  same  cause. 

Treatment, — No  disease  is  more  likely  to  be  benefited  by  early 
venesection  than  acute  inflammation  of  the  brain. ■^  Bleeding 
should  be  the  rule  — omission  of  it  the  exception — necessary  in 
cases  of  debility,  ana?mia,  etc.  But  its  usefulness  depends  upon 
its  being  early  ;  and  it  should  seldom  be  repeated.  Leeching  or 
cupping  may  follow  it,  or  sometimes  take  its  place.  In  children, 
the  difficulty  of  finding  a  convenient  vein  to  open  may  induce 
dependence  upon  leeches  or  cups. 

Purging  actively  is  very  important,  by  sulphate  or  citrate  of 


1  See  a  paper  by  Drs.  S.  W.  Mitchell  and  W.  Thompson,  Am.  Journal  of  Med.  Sciences, 
July,  1874,  p.  104. 

-  Dr.  Rush  (179S)  pave  an  account  of  the  recovery  of  seven  severe  cases  of  inflamma- 
tion of  the  brain  under  venesection.  Dr.  E.  Copenian  (Report  on  the  Cerebrnl.  Affections 
of  liifancij,  etc.,  lS7o)  cites,  in  favor  of  the  same  practice,  Joy,  Stewart,  Risdou  Bennett, 
Clarke,  IJavis,  and  other  authorities. 

29  W 


338   DISEASES   OF   BRAIN   AND   NERVOUS  SYSTEM. 

magnesium,  or,  if  closing  be  difficult  from  delirium,  croton  oil  [F. 
127]  or  elaterium.  After  one  free  purging,  moderate  catharsis 
may  be,  if  necessary,  repeated  every  two  or  three  days ;  and  the 
bowels  should  be  kept  open  through  the  attack. 

Cutting  the  hair  very  short,  or,  still  better,  shaving  the  whole 
head,  will  aid  in  giving  relief,  and  will  allow  the  effectual  applica- 
tion of  cold.  Pounded  ice  in  a  bladder  or  bag  of  india-rubber, 
will  do  if  watched  and  changed  in  place  often,  to  prevent  too 
great  an  impression  upon  one  part.  1  prefer  a  linen  cloth  (as  a 
cambric  handkerchief)  folded  once,  dipped  in  ice-vmter,  and  laid 
over  the  head  ;  it  should  be  wet  freshly  every  few  minutes^  or  the 
good  effect  is  almost  lost.  Merely  wetting  the  heat  now  and  then 
with  cold  water  produces  a  reaction,  not  a  sedation,  which  is 
required.  Knomsley  Thornton's  ice-cap  is  a  good  application,  if 
the  patient  is  not  too  restless  to  allow  it  to  remain  in  place.  It 
is  a  coil  of  india-rubber  tubing,  through  which  a  stream  of  ice- 
water  is  made  to  flow  constantly.  If  the  feet  be  cold,  they  should 
be  made  warm  by  mustard  foot-baths  or  sinapisms.  In  children, 
the  prolonged  warm  bath  may  be  useful. 

The  diet  in  the  first  part  of  the  attack  should  be  as  light  and 
unstimulating  as  possible.  Oatmeal  gruel,  panada,  rice,  toast- 
water,  may  come  first ;  then  milk,  chicken-water,  mutton-broth ; 
later,  beef-tea. 

Blisters  are  undoubtedly  serviceable  after  the  intensity  of  the 
inflammatory  excitement  has  begun  to  diminish.  The  best  will 
be  a  blister  over  the  whole  scal]?.^ 

In  a  late  stage,  with  secondary  debility,  concentrated  liquid 
diet,  with  alcoholic  stimulants,  and  even  opium,  or  bromide  of 
potassium  at  night,  may  be  required  to  support  the  flagging  ener- 
gies of  the  system. 

Convalescence  in  the  best  cases  may  be  slow.  The  faculties  may 
remain  feeble  and  the  brain  morbidly  excitable  for  weeks  or 
months  ;  needing  great  care  as  to  all  mental  impressions  and 
efforts,  lest  a  dangerous  relapse  occur,  or  chronic  cerebral  hyper- 
semia,  perhaps  insanity,  follow. 

Chronic  inflammation  of  the  brain  or  its  membranes,  of  a  sim- 
ple form,  is  no  doubt  met  with,  but  seldom  distinctly  diagnos- 
ticated. Sub-acute  encephalitis  (phrenitis)  frequently  has  part 
(Forbes  Winslow)  in  the  pathogeny  of  insanity ;  especially  acute 
mania.  Peri-encephalitis,  of  a  chronic  character,  is  asserted  by 
E.  C.  Seguin^  to  account  for  the  symptoms  of  what  is  called  by 
him  paralytic  dementia  ;  more  generally  denominated  general 
paralysis. 

Scrofulous  Encephalitis  (tubercular  meningitis,  acute  hydro- 
cephalus).— From  two  to  fifteen  years  is  the  age  most  apt  to  yield 
examples  of  this  fatal  disease.  Evidences  of  the  scrofulous  con- 
stitution have  mostly  been  manifested  in  the  previous  histor)^  of 
the  patient.  Premonitory  symptoms  usually  occur  :  dulness,  pet- 
tishness,  and  languor,  headache,  disposition  to  put  the  head  in 
the  mother's  lap  or  to  lie  down,  loss  of  appetite,  vomiting,  and 

1  I  cannot  follow  Dr.  T.  K.  Chambers  (Havveian  Oration,  1871,  p.  8)  in  including  this 
treatment  among  extinct  procedures.     I  am  sure  I  have  known  it  to  do  great  good. 

2  N.  Y.  Med.  Record,  Feb.  26,  1881,  p.  328. 


INFLAMMATION     OF    THE     BRAIN.  339 

either  costiveness  or  diarrliocn.  The  child  sleeps  ill,  with  grinding 
of  the  teetli,  or  sudden  starting  with  alarm.  After  four  or  five 
days,  constant  headache  and  anxiety  of  countenance,  heat  of  head, 
sensitiveness  to  light,  fever,  and  drowsiness,  alternated  with 
moaning  or  occasional  screwiidng^  and  delirium  at  night,  mark  the 
case.  In  the  middle  period  may  he  observed  the  "  tache  menin- 
gitique"  of  Trousseau,  ?'.  c,  drawing  a  linger  across  the  forehead 
or  the  abdomen ;  upon  removing  it  a  pink  or  rose-red  line  will 
remain  for  a  time,  gradually  disappearing. 

Advanced  symptoms  are,  total  stupor,  strabismus,  convulsions, 
paralysis,  and  rigidity  of  the  liml)s.  The  pu^^^  generally  goes 
through  similar  changes  to  those  of  simple  encephalitis  :  first, 
febrile  acceleration,  then  irregularity  and  slowness,  lastly,  the 
rapidity  of  moribund  prostration.  The  attack  terminates  on  the 
average  in  between  two  and  three  weeks. 

Prognosis  is  always  unfavorable  in  this  disorder.  I  thought  I 
had  met  with  recovery  in  one  case,  the  third  of  his  family  to  be 
attacked  ;  he  remained  well  apparently  for  a  month,  and  then 
died  in  convulsions.  Dujardin-Beaumetz  has  reported  a  case  of 
recovery  from  tubercular  meningitis  in  an  adult.' 

Morbid  Anatomy. — Since  '^  Papavoine,  Kufz,  and  Gerhard 
showed  the  existence  of  a  relation  between  tuberculosis  and 
"acute  hydrocephalus,"  autopsic  inquiry  has  proved  fully,  1st, 
that  tubercle-like  granulations,  with  opacity  and  thickening  of 
the  arachnoid  at  the  base  of  the  brain,  adhesion  between  the 
hemispheres,  and  serous  effusion,  characterize  a  number  of  the 
cases  ;  2dly,  that  all  of  the  other  lesions  may  be  found  without 
any  tubercle  whatever  ;  and  3dly,  that  the  amount  of  such  deposit 
in  most  cases  is  not  sufficient  to  modify  greatly  the  course  of  the 
local  disease,  at  least  in  such  a  manner  as  tubercle  acts  elsewhere. 
I  conclude  hence  (especially  in  view  of  such  results,  palpably 
shown  in  autopsy  under  my  own  eye),  that  the  semi-transparent 
gray  granulations  found  in  the  arachnoid  after  scrofulous  menin- 
gitis may  be  rather  tubercular  inflammatory  products  than  tuber- 
cles, while  it  is  more  the  diathesis  than  the  deposit  that  makes  the 
disease  to  differ,  as  in  progress  and  prognosis  it  clearly  does,  from 
simple  meningitis  or  encephalitis. 

Treatment. — What  can  we  venture  to  do  in  medication  for  a 
hopeless  disease  ?  Not  to  abandon  any  case  of  it ;  for,  first,  our 
diagnosis  may  not  be  infallible  ;  and,  secondly,  there  are  not,  as 
in  phthisis,  obvious  anatomical  reasons  for  anticipating  a  fatal 
result  in  the  nature  of  the  case.  Waiving  argument,  for  which 
we  have  no  space,  my  judgment  is  in  favor  of  treating  this  form 
of  inflammation  of  the  brain  o?i  the  same  pirinciple  as  simple  menin- 
gitis, with  more  caution  in  depletion  and  other  reducing  remedies. 
I  would  not  bleed  from  the  arm  ;  but  draw  blood  very  moderately 
by  cups  and  leeches ;  purge  freely,  but  not  exhaustively  ;  blister 
the  head  or  back  of  the  neck  ;  apply  cold  with  care,  and  allow 
liquid  nourishment,  such  as  milk  and  beef-tea,  mutton  or  chicken 
broth,  etc. ,  from  an  early  stage.  Iodide  (or  bromide  ?)  of  potassium 

1  Le  rrogrgs  Medical,  1879,  p.  208. 

"  Leauucc  observed  the  presence  of  tubercles  in  the  braiu  in  some  cases  of  hydro- 
cephalus. 


340    DISEASES   OF   BRAIN   AND   NERVOUS   SYSTEM. 

may  be  given  at  least  in  protracted  cases.  If,  in  this  mode, 
we  do  not  save  a  patient  whom  autopsy  afterwards  shows  to  have 
been  doomed  to  die  of  tuberculization  in  spite  of  any  treatment, 
we  shall  still,  according  to  the  indications  of  clear  analogy,  have 
practised  rationally  ;  the  next  best  thing  to  being  successful. 

HYDROCEPHALUS. 

Definition. — Water  in  the  head  ;  dropsy  of  the  brain.  This  is 
almost  always  an  affection  of  early  life.  Sometimes  it  is  congen- 
ital. It  is  mostly  a  passive  dropsical  effusion  ;  certain  cases  show 
signs  of  a  chronic  or  subacute  inflammatory  condition  of  the 
arachnoid  membrane. 

Symptoms. — Languor,  strabismus,  convulsions,  loss  of  appetite, 
increase  in  the  size  of  the  head.  This  last  may  be  enormous  ; 
the  fontanelles  expanding,  and,  in  a  slow  case,  the  bones  growing 
excessively  large.  The  mental  faculties  are  nearly  always  dull. 
Bodily  emaciation  and  debility  attend. 

Although  cases  are  known  and  recorded  in  which  hydrocephalic 
persons  have  lived  for  jnore  than  twenty  years,  the  general  rule  is 
that  they  die  in  a  few  months  ;  either  from  cerebro-spinal  dis- 
ability or  atrophy,  or  from  some  intercurrent  disease  not  endur- 
able by  the  impaired  vital  energy  of  the  system. 

The  term  "  hydrencephaloid  disease"  is  a  term  applied  by 
Marshall  Hall  to  a  condition,  not  very  rare  in  infants,  in  which 
symptoms  resembling  those  of  acute  hydrocephalus  occur,  with 
functional  brain  disorder  only.  The  diagnosis  is  here  not  always 
easy ;  but  with  close  attention  it  may  be  made  out.  While  a 
doubt  exists,  reducing  measures  are,  generally,  to  be  avoided. 
Dr.  W.  Nickoll  has  given  the  name  ''cerebral  erythism"  to  a 
transitory  determination  of  blood  to  the  brain,  with  signs  of 
excitement,  in  children. 

Treatment. — Small  as  is  the  encouragement  given  by  experience 
in  hydrocephalus,  it  is  certainly  justifiable  to  try  measures  not  out 
of  place  in  themselves.  Such  are,  moderate  purging,  every  few 
days,  or  once  a  week,  sustaining  the  strength  by  nourishing  food, 
and,  if  it  be  borne,  cod-liver  oil ;  diuretics  ;  shaving  the  head  and 
rubbing  it  nightly  with  mercurial  ointment ;  occasionally  blister- 
ing the  back  of  the  neck  ;  in  a  child,  preferably  by  painting  it 
with  cantharidal  collodion. 

Is  pressure  by  bandages  or  adhesive  straps,  or  puncture,  tapping 
the  head,  to  be  advised  ?  Were  I  to  use  either  of  these  heroic 
measures,  I  would  combine  them.  In  a  case  clearly  otherwise 
hopeless,  the  aspirator  may  be  used,  or  a  needle  trocar  and  canula 
may  be  introduced  through  the  coronal  suture,  an  inch  or  a  little 
less  from  the  anterior  fontanelle  :  then,  during  and  after  the  with- 
drawal of  a  few  ounces  of  fluid,  a  bandage  may  be  used  for  pres- 
sure, watching  its  effects.  Dr.  West  has  collated  accounts  of 
sixty-three  operations  by  puncture,  of  which  eighteen  were 
successful. 

BRAIN  EXHAUSTION. 

Under  the  pressure  of  intense  competition  in  modern  society 
for  wealth,  reputation,  or  political  power,  or    sometimes,  from 


BRAIN    EXHAUSTION.  341 

the  needs  of  professional  oi'other  unavoidalHe  duties,  break-down 
often  happens  from  "wear  and  tear"  (Mitcliell).  This  may  he 
an  exliaustion  of  the  total  energy  of  the  hody,  or  it  may  almost 
exelusively  involve  the  brain.  If  the  latter,  there  are  usually 
premonitory  symptoms.  First  of  these,  in  many  cases,  is  drowsi- 
ness and  in(iis])osition  toward  mental  effort.  Intensity  of  tempera- 
ment, or  excitement  of  motive,  may  often  prevent  or  overcome 
this.  Then  comes  a  sense  of  tightness,  perhaps  numbness,  in 
the  back  of  the  head  and  neck.  Afterwards,  insomnia;  with 
perceptible  throl)bing  of  the  arteries  at  the  base  of  the  brain  ; 
tinnitus  auriuni ;  muscce  volitantes  before  the  eyes ;  nausea,  or 
diarrhrea ;  attacks  either  syncopal  or  epileptoid,  especially  at 
night ;  "leg-heavy  "sensations,  approaching  paralysis  ;  and  other 
evidences  of  cerebral  "neurasthenia." 

Treatment. — The  indispensable  remedy  here  is  brain  rest ;  imme- 
diate, total,  and  prolonged.  Especially  must  the  pursuit  or 
engagement  be  at  once  given  up,  which  has  overtaxed  the  brain. 
Of  course  this  is  often  difficult,  especially  because,  much  most 
frequently,  it  is  the  emotional  care  or  worry  which  has  done  the 
mischief.  I  am  sure,  nevertheless,  that  without  any  worry, 
excessive  brain  work,  when  abundant  sleep  is  not  taken,  may 
exhaust  the  brain  seriously.  Leaving  home  is  commonly  advised, 
to  afford  the  benefit  of  a  change  of  mental  impressions.  But 
these  impressions  must  not  be  too  exciting  or  fatiguing.  In  my 
own  case,  a  winter  in  Egypt  relieved  obstinate  insomnia;  it 
returned  at  once  among  the  picture-galleries  and  other  sights  of 
European  travel. 

Medicinal  treatment,  in  such  cases,  is  mostly  secondary,  apart 
from  what  may  be  called  for  on  account  of  the  general  condition 
of  the  body.  Cautious  use  may  be  made  of  quinine,  strychnia, 
and  phosphorus,  as  nervine  tonics ;  beginning  with  minimum 
doses,  and  watching  their  effects.  Besides  these,  insomnia  may 
be  treated  (also  tentatively)  with  bromide  of  potassium,  tincture 
of  valerian,  valerianate  of  ammonium,  tincture  of  lupulin  ;  reserv- 
ing hydrate  of  chloral,  hysoscyamus  and  opiates  for  a  late 
necessity.  Alcohol,  in  small  doses  (e.  r/.,  a  tumbler  of  lager  beer 
at  bed-time)  is  often,  in  such  cases,  the  most  effective  of  all 
hypnotics  ;  but  its  use  is  accompanied  by  more  danger  of  injurious 
excess  than  that  of  any  of  the  others.  A  semi-recumbent  position 
not  unfrequently  promotes  sleep,  when  the  over-full  state  of 
the  cerebral  arteries  makes  the  recumbent  position  one  of  wake- 
fulness. 

Slow  recovery,  only,  is  always  to  be  expected  in  cases  of  decided 
brain  exhaustion.  From  one  to  three  years  of  rest,  as  nearly 
absolute  as  possible,  from  accustomed  "wear  and  tear,"  will 
commonly  be  required.  When  the  attack  occurs  late  in  life, 
recuperation  is  seldom  possible  ;  the  day's  work  is  done.  Either 
simple  disability  for  mental  exertion  remains,  or  some  form  of 
cerebral  disease  shortens  life  ;  apoplexy,  paralysis,  etc.,  coming  on. 

Wisdom  prescribes,  on  the  part  of  every  brain  worker,  catdion 
in  heeding  every  sign  of  approaching  cerebral  exhaustion  ;  most 
of  all,  care  to  obtain  a  sufficient  amount  of  sleep  every  night  or 
day,  or,  at  least,  sotnetime  in  every  week, 
29* 


342    DISEASES   OF  BRAIN  AND   NERVOUS  SYSTEM. 


SOFTENING   OF   THE   BRAIN. 

Pathologists  have  generally  recognized  two  forms  of  this :  1. 
Acute  red  mflammatory  softening  ;"and,  2.  Slow,  white,  atrophie 
softening  or  degeneration  of  the  brain-substance.  Both  receive 
the  name  of  ramolUssement.  Yirchow  has  proposed  the  term 
necrobiosis  (death  of  a  part  in  the  midst  of  living  structure),  to 
designate  destructive  local  change  in  any  part  of  the  body. 

The  former  of  these  (red  softening)  is  further  definable  as  a 
local  cerebritis ;  whose  symptoms  are  not  nearly  always  separ- 
able, clinically,  from  those  of  meningitis  or  encephalitis,  already 
described.  Cadaveric  inspection  shows  not  only  hypera^mic  red- 
ness and  softening,  but,  sometimes,  abscess,  or  even  gangrene  of 
the  brain.  This  last  (gangrene)  is  probably  always  the  result  of 
injuries.  The  cerebrum  is  more  often  affected  with  red  softening 
than  the  cerebellum. 

Abscess  of  the  brain  is,  in  some  cases,  latent  for  a  considerable 
time.  Sudden  headache  is  apt  to  be  the  earliest  symptom.  This 
is  attended  by  feverishness,  vomiting,  difficulty  of  speech,  numb- 
ness, convulsions,  paralysis,  and  coma.  Otitis  and  pycemia  are 
said  to  be,  after  injuries,  the  most  frequent  direct  causes  of  it. 
Abscess  of  the  cerebellum  is  occasionally  met  with.  Its  symp- 
toms are  variable  and  obscure  ;  sometimes  only  muscular  debility 
is  observed  before  death.  Nothnagel  asserts  that  disorder  of 
coordination  (want  of  control  of  the  muscles,  abnormal  move- 
ments) occurs  when  the  vermiform  process  or  median  cerebellar 
lobe  is  affected. 

Diagnosis  of  Acute  Softening". — The  occurrence  of  imperfect 
coma,  with  rigidity  of  the  muscles  of  the  extremities,  or  of  paral- 
ysis without  loss  of  consciousness,  will  make  probable  this 
lesion.  Most  cases  die  within  two  weeks  ;  some  within  two  or 
three  days. 

Atrophic  softening  or  degeneration  of  the  brain  may  take 
place  as  a  result  of  old  age,  or  from  intense  mental  labor  or 
excitement,  from  intemperance,  or  from  thrombosis  or  embolism  ; 
that  is  obstruction  of  an  artery  within  the  brain  by  a  fibrinous 
clot  formed  in  the  vessel  or  carried  from  some  other  part.  Its 
approach  and  progress  are  more  slow  and  insidious  than  those  of 
acute  inflammatory  ramollissement.  Neuralgic  pains  in  the  limbs, 
followed  by  numbness  and  paralysis  ;  general  debility,  and  dul- 
ness  of  the  senses,  gradually  increasing  to  blindness,  loss  of  hear- 
ing, etc.,  and  a  corresponding  decline  of  the  mental  powers; 
these  are  the  usual  symptoms,  which  may  be  extended  over  a 
period  of  many  months.  Death  is  sure  to  be  the  final  result. 
Hughlings-.Jackson  (the  highest  recent  authority  on  cerebral 
pathology)  asserts  (1880)  that "  cerebral  softening  is  always  local, " 
never  general  through  the  brain;  and  that  (except  occasional 
instances  following  local  inflammation)  its  cause  is  always  blocking 
of  cerebral  ■uesse7s; ^either  by  thrombosis  or,  less  often,  by  embolism. 
The  middle  cerebral  artery  is  the  vessel  most  apt  to  be  thus 
obstructed;  and  the  resulting  symptoms  are  chiefly  those  of 
hemiplegia  and  impairment  of  speech. 

Sclerosis  of  the  brain  is  a  term  applied  by  Proust  and  others  to 


INFLAMMATION    OF    THE    EYE.  343 

a  chronic  orijanic  anVctioji'  in  which  the  ccrchral  substance 
becomes  hardened^  instead  of  softening.  To  this  more  attention 
will  be  given  presentl}'. 

Glioma  is  a  kind  of  tumor  (most  frequent  in  early  life)  affecting 
the  neuroglia  or  connective  tissue  of  the  brain,  retina,  or  nerves. 

Treatment.— If  inflammatory  red  softening  can  be  diagnosti- 
cated at  an  early  period,  a  similar  treatment  to  that  named  for 
acute  meningo-encephalitis  may  be  advised.  Local  depletion  at 
least,  followed  by  counter-irritation  with  blisters,  may  be  resorted 
to  ;  the  more  freely  because  apoplexy,  which  most  nearly  simulates 
it,  presents  very  similar  practical  indications. 

Chronic  Atrophic  White  Softening  is  not  amenable  to  any  such 
measures  ;  nor,  indeed,  to  any  active  remedial  treatment.  Pre- 
vention, by  avoidance  of  its  causes,  especially  by  mental  repose, 
and  palHation  or  economy  of  the  waning  powers  of  the  system, 
are  alone  possible.  The  management  necessary  upon  such  indi- 
cations must  vary  somewhat  with  every  case. 

INFLAMMATION   OF  THE  EYE. 

Although  ophthalmology  is  appropriated  as  a  department  of 
surgery,  every  medical  practitioner  meets  with  cases  of  affections 
of  the  eye  so  often,  as  to  make  it  proper  to  notice  here,  briefly, 
its  principal  acute  disorders. 

Varieties. — Conjunctivitis  {ophthalmia^  by  usage),  simple,  catar- 
rhal, pustular,  and  purulent  (Egyptian,  military,  and  gonor- 
rhoea! ophthalmia,  and  ophthalmia  veonatorum,  i.  e.,  of  new-born 
infants) ;  keratitis  (corneitis) ;  sclerotitis  (rheumatic  ophthal- 
mia); iritis  (simple,  traumatic,  syphilitic);  retinitis. 

Simple  and  Catarrhal  Ophthalmia:  Symptoms.— Bloodshot 
appearance  of  the  eye,  with  soreness,  pain,  and  dislike  of  light, 
characterize  simple  conjunctivitis.  Blotched  or  irregular  injec- 
tion of  tlie  conjunctiva,  becoming  in  severe  cases  general  and 
velvet-like,  with,  sometimes,  chemosis  (raising  of  the  mucous 
membrane  in  spots,  like  little  water  blisters)  and  mucous  dis- 
ciiarge,  agglutinating  the  lids  together,  especially  at  night;  these 
are  the  symptoms  of  the  catarrhal  variety  or  grade. 

Treatment. — When  the  inflammation  is  severe  and  recent, 
leeches  to  the  temple  near  the  eye  will  do  good.  Iced  sassafras- 
pith  water  may  be  applied  by  laying  a  light  piece  of  linen,  soaked 
anew  every  few  minutes,  over  the  closed  lids ;  or,  better,  by  the 
frequent  use  of  a  clean  camel's-hair  pencil  dipped  in  the  cold 
demulcent  liquid.  Nitrate  of  silver  solution,  two  grains  to  the 
ounce  of  distilled  water,  is  recommended  to  be  dropped  from  a 
quill  or  camel's-hair  pencil  into  the  eye,  twice  daily.  A  saline 
cathartic  at  the  beginning  of  the  attack  will  generally  be  useful ; 
and  so  will  be,  a  little  later,  a  fly-blister  behind  the  ear.  When 
convalescence  has  fairly  commenced,  the  use  of  the  injection 
may  be  made  at  longer  intervals,  once  in  a  day  or  two ;  the  eye 
being  then  kept  closed,  if  the  mucous  discharge  be  slight,  by  a 
strip  of  isinglass  plaster  over  the  middle  of  both  lids.  After 
recover}',  the  eyes  will  be  weak  for  a  time,  and  must  be  used 
with  caution  and  moderation.     Adhesion  of  the  lids  is  best  pre- 


344   DISEASES   OF   BRAIN   AND   NERVOUS   SYSTEM, 

vented,  at  any  stage,  by  the  application  of  spermaceti  ointment, 
castor  oil,  or  glycerin  cream,  to  their  margin. 

Persistent  redness  and  swelling  of  the  lids  will  often  give  way, 
under  the  use,  nightly,  as  an  unguent,  of  the  cerate  of  carbonate 
of  lead  [r.  88].  Painting  the  exterior  of  the  lids,  many  times 
daily,  by  means  of  a  camel's-hair  pencil,  with  diluted  extract 
of  lead  (one  drop  of  Goulard's  extract  in  an  ounce  of  water), 
followed  by  cold  cream  or  glycerin  cream  at  night,  has,  to  my 
knowledge,  relieved  greatly  cases  of  long-standing  "weakness  " 
or  irritability  of  the  eyes.  When  ulceration  of  the  cornea  is 
present,  the  use  of  lead  should  be  avoided,  for  fear  of  opacity 
being  produced.  Granular  conjunctiva^  or  "chronic  ophthal- 
mia," not  yielding  to  the  above  measures,  may  be  referred  to 
the  resources  of  the  special  ophthalmologist.  Among  the  more 
recent  useful  applications  for  it  may  be  mentioned  iodoform^ 
applied  in  fine  powder  with  a  hair  pencil.  Another  is  horacic 
acid,  in  solution  (Theobald),  2  to  4  grains  in  the  ounce  of  water. 
Pustidar  ophthalmia  is  characterized  by  the  formation  upon  the 
conjunctiva  of  small  vesicular  elevations  resembling  pustules, 
although  rarely  discharging  pus.  In  other  respects,  the  attack 
resembles  catarrhal  inflammation. 

Purulent  Ophthalmia.— 1.  Ophthalmia  of  infancy.  Leucor- 
rhoea  or  gonorrhoea  of  the  mother  may  produce  this  ;  or  it  may 
follow  exposure  to  cold  or  damp  air,  acting  upon  a  system  pre- 
disposed by  imperfect  nutrition.  The  danger  of  it  is,  the  possi- 
bility of  rapidly  destructive  ulceration  of  the  cornea,  causing 
blindness.  It  is  possible,  however,  for  a  considerable  ulcer  of 
the  cornea  to  heal,  in  a  child,  even  without  leaving  an  opaque 
cicatrix. 

Treatment. — Introduce,  by  inserting  the  smooth  point  of  a 
small  syringe  just  within  the  inner  commissure  of  the  lids,  sev- 
eral times  a  day,  a  solution  of  three  grains  of  alum  to  the  ounce 
of  water ;  alternated  occasionally  with  a  solution  (one  or  two 
grains  to  the  ounce)  of  nitrate  of  silver.  Boracic  acid  solution 
(gr.  V  to  XV  in  fgj)  is  also  worthy  of  trial ;  and,  later,  solution 
of  atropia.  As  very  much  depends  upon  the  vital  energy  of  the 
child's  system,  especial  care  must  be  taken  as  to  its  nourish- 
ment, bathing,  and  the  state  of  its  bowels. 

2.  Gronorrhoeal  Ophthalmia.  —  Produced  by  contact  of  the 
virulent  poison  of  gonorrhoea,  this  is  perhaps  the  worst  form 
of  inflammation  of  the  eye.  At  the  beginning,  it  (as  well  as 
ordinary  purulent  ophthalmia)  may  resemble  catarrhal  inflam- 
mation ;  but  its  course  is  so  rapid  and  violent  as  to  become  sup- 
purative in  one  or  two  days.  Haziness  of  the  cornea,  and  che- 
mosis,  followed  by  ulceration,  perforation,  or  sloughing,  may 
occur.  Such  ulcers  are  apt  to  leave  white  and  opaque  cicatrices, 
even  if  not  very  deep,  in  the  adult. 

Treatment. — Begin  Avith  a  brisk  purgation.  Then  apply,  at 
once,  and  frequently,  in  alternation,  solution  of  alum,  ten  grains 
In  an  ounce,  and  solution  of  nitrate  of  silver,  four  grains  in  an 
ounce.  If  the  specific  character  of  the  inflammation  can  thus  be 
annulled,  the  destruction  of  the  cornea  maybe  averted.  Some- 
times good  surgeons  have  applied  the  solid  nitrate  of  silver  to 


INFLAMMATION    OP    THE    EYE.  345 

the  ulceralcMl  surface.  Theobald  recommends  (iV.  Y.  Med.  liecord^ 
Feb.  7,  ISSO),  a  2U-t,a'aiii  solution  of  boracic  acid.  The  prognosis, 
however,  in  this  form  of  disease,  is  generally  unfavorable  to  the 
safety  of  vision. 

Keratitis  (Oorneitis). — A  zone  of  vessels  in  the  sclerotic, 
immediately  surrounding  the  cornea,  with  haziness  in  the  latter 
itself,  amounting  in  time  to  opacity,  marks  this  affection.  When 
developed,  we  will  find  a  plexus  of  fine  vessels  arranged  in  a 
crescent  or  semicircle,  along  the  upper  or  lower  edge  of  the  cornea, 
or  both.  Intolerance  of  light  is  great ;  any  exposure  of  the  eye 
causes  a  flow  of  tears.  Children  and  adolescents  are  most  gener- 
ally the  subjects  of  inflammation  of  the  cornea.  It  may  be  of 
short  duration,  the  opacity  disappearing,  in  a  young  person  ;  at 
a  later  period  of  life,  it  is  more  obstinate  ;  and  if  the  attack 
lingers  for  several  months,  cloudiness  remains. 

Treatment.— Most  subjects  of  corneal  inflammation  are  of  deli- 
cate frame  and  depressed  health.  Tonics  and  good  diet  are  more 
likely,  in  them,  to  be  indicated  than  depletion.  Repeated  blister- 
ing behind  the  ears  will  be  proper.  The  bowels  should  be  well 
opened,  and  the  eyes  sheltered  from  strong  light,  while  photo- 
phobia (intolerance  of  light)  exists.  In  no  form  of  disease  of  the 
eye,  however,  unless  for  a  short  time  in  a  very  acute  attack, 
should  a  patient  be  imprisoned  in  a  dark  room.  The  want  of  air, 
and  even  of  sunshine,  will  do  more  harm  than  good.  When 
otherwise  in  a  state  fit  for  it,  he  may  go  out  with  the  eyes  pro- 
tected by  a  shade  or  suitable  glasses,  or  a  veil.  Good  authority 
prohibits  the  use  of  nitrate  of  silver  solutions  as  mischievous  in 
corneal  inflammation.  If  ulceration  of  the  cornea  occur,  lead  in 
any  form  is  forbidden,  lest  a  deposit  of  albuminate  of  lead  should 
cause  opacity.  Iodoform  has  been  found  (applied  in  fine  powder 
with  a  hair  pencil)  beneficial  in  some  cases  of  obstinate  keratitis. 

Sclerotitis ;  rheumatic  ophthalmia.  This  is  shown  by  diffused 
redness  of  the  eyeball,  with  enlargement  of  the  arteries  converg- 
ing to  the  margin  of  the  cornea;  and  severe  pain  in  the  ball,  with 
intolerance  of  light. 

Treatment.— Not  satisfied  that  there  is  always  proof  of  the 
"rheumatic  diathesis"  in  every  case  of  sclerotic  inflammation,  I 
should  still  incline  to  prescribe  for  it,  as  a  general  rule,  a  combina- 
tion of  colchicum  with  an  alkali  (as  carbonate  of  potassium), 
after  a  saline  cathartic.  A  blister  may  then  be  applied  behind 
the  ear  or  back  of  the  neck.  Anodynes  are  apt  to  be  called  for  ; 
as  belladonna  or  opiates  ;  so  severe  is  the  pain  in  many  instances. ' 

Iritis. — Writers  describe  the  forms  of  inflammation  of  the  iris 
as  simple,  traumatic,  gouty  and  rheumatic,  scrofulous,  and 
syphilitic.  The  first  and  last  of  these  are  the  most  important 
and  distinctive. 

In  either  form  of  inflammation,  a  vascidar  zone  in  the  sclerotic, 
near  the  cornea,  fixedness  and  irregidarity  of  the  pupil,  with  a 
greenish  hue  of  the  iris,  if  it  be  naturally  blue,  are  the  usual 
signs. 

Treatment. — In  a  robust  patient,  leeches  around  the  eyes  ;  in  a 
weaker  one,  a  blister  behind  the  ear  ;  saline  purgation,  repose  to 
the  eye,  and  steaming  it  frequently  over  hot  water,  are  measures 


346    DISEASES   OF    BRAIN   AND    NERVOUS   SYSTEM. 

that  nearly  all  will  agree  upon.  More  diflference  of  opinion  exists 
as  to  the  use  of  mercury  in  iritis.  Some  give  it  with  the  hope  of 
retarding  the  effusion  of  lymph  in  all  cases.  Others,  only  in  the 
syphilitic.  A  number,  rather  increasing  of  late,  in  none.  I  would 
give  calomel  in  all  cases  of  active  iritis,  but  in  none  so  largely  as 
to  endanger  salivation.  One  grain  twice  daily  for  a  few  days 
will  be  enough  ;  stopping  it  if  the  gums  be  at  all  affected. 

Maintaining  moderate  dilatation  of  the  pupil  is  considered 
important  in  cases  of  iritis.  For  this  purpose  atropia  is  locally 
used.  Once  or  twice  daily  there  may  be  dropped  into  the  eye 
two  or  three  drops  of  a  solution  of  two  grains  of  sulphate  of 
atropia  in  an  ounce  of  water. 

In  all  forms  of  severe  inflammation  of  the  textures  of  the  eye, 
Dr.  C.  R.  Agnew  considers  the  Turkish  (hot-air)  bath  an  impor- 
tant measure  of  treatment. 

Retinitis. — So  obscure  is  the  diagnosis  of  this,  and  so  greatly 
has  its  pathology  been  modified  since  the  introduction  of  the 
ophthalmoscope,'  that  it  will  be  the  best  to  refer  for  its  consider- 
ation to  works  especially  upon  the  eye. 

Betinal  apoplexy^  or  hemorrhage  of  the  retina,  sometimes  occurs ; 
especially  in  connection  with  cerebral  or  cardiac  disease.  It  is 
generally  sudden,  causing  partial  or  total  blindness.  (See  a  paper 
by  Dr.  C.  S.  Bull,  Am.  Journal  of  Med.  Sciences^  July,  1874.)  It 
has  been  met  with  in  a  number  of  cases  of  progressive  pernicious 
anaemia. 

OTITIS. 

Definition. — Inflammation  of  the  ear.  This  is  most  common  in 
children.  Scrofulous  inflammation  and  suppuration  of  the  external 
meatus,  with  chronic  discharge,  is  frequently  met  with.  Scarlet 
fever  not  rarely  is  attended  by  otitis,  extending  from  the  throat ; 
sometimes  ulceration  destroys  the  membrana  tympani,  and  even 
the  ossicula,  causing  deafness. 

Otalgia,  earache,  occurs  often  without  much  inflammation,  as 
an  almost  entirely  neuralgic  affection.  Pain,  however,  is  the  first 
symptom  of  otitis  ;  with  soreness  on  pressure  upon  the  meatus  or 
the  mastoid  process,  and  heat  of  the  ear.  An  infant  may  suffer 
from  this  without  being  able  to  designate  the  seat  of  its  distress. 
It  cries  or  screams  at  intervals,  and  buries  its  head  in  the  pillow, 
or  leans  the  affected  side  against  its  mother's  breast  or  arm. 
Often  in  the  course  of  a  day  or  two  a  purulent  discharge  gives 
"  relief  to  the  intensity  of  the  attack.  In  other  cases  pain  returns 
again  and  again,  the  soreness  continuing  without  discharge  for 
weeks  together. 

1  In  acute  inflammations  of  the  eye  or  brain  its  use  appears  to  me  unsuitable,  on 
account  of  the  intense  irritation  likely  to  attend  the  steady  glare  of  a  direct  light  upon 
the  already  morbidly  sensitive  eye.  Bouchut,  however,  has  written  a  volume  upon  it 
as  a  means  of  diagnosis  in  diseases  of  the  brain,  as  meningitis,  etc.  In  amaurosis,  an 
Important  distinction  has  been  made  out  between  those  cases  dependent  upon  nevrilis 
oplici  intraocularis  (inflammation  of  the  optic  nerve  within  the  eye),  and  those  which 
are  entirely  paralytic  in  nature.  Forster,  Hirschberg,  and  Nettleship  have  shown  that 
excessive  use  of  tobacco  often  causes  amblyopia  (dimness  of  vision),  resembling  amaurosis. 
In  defects  of  vision  connected  with  loss  of  functional  power  in  the  optic  nerve.  Dr.  D. 
Dyce  Brown  has  found  santonin  (1  gr.  daily)  very  useful.  See  Brit,  and  For.  Med.-Chir. 
Eev.,  April,  1871. 


O  T  1  'i'  1  S  .  ii4:7 

Extension  of  in(l:unni!ition.  from  the  external  ear  to  the  mem- 
branes of  the  brahi  is  possible  in  severe  aeute  otitis ;  but  it  is 
almost  as  lil<ely  to  happen  in  eases  of  long-eontinued  otorrjifjpxi, 
or  (liseharge  from  the  ear ;  pai'ticularly  if  this  be  suddenly 
arrested. 

Dr.  Lldell  and  others  have  pointed  out  that  the  produetion  of 
cerebral  thro^nhosis  (obstructicm  from  coagulation  in  a  vein  or 
veins  within  the  cranium)  is  one  of  the  dangers  of  otitis. 
Sometimes  the  connecting  link  between  the  two  affections  is 
caries  or  necrosis  of  the  petrous  portion  of  the  temporal  l)one. 

Treatment. — Earache  may  be  relieved  usually  by  dropping  into 
the  ear  three  or  four  drops  of  olive  or  almond  oil,  with  one  or  two 
drops  of  laudanum.  If  continued  pain,  with  heat  and  tenderness 
on  pressure  show  decided  inflammation,  a  few  American  leeches 
may  be  applied  behind  the  ear;  and  afterwards  a  small  blister 
(when  the  leech-bites  have  healed)  upon  the  same  place.  Painting 
with  the  cantharidal  collodion  will  here  prove  very  convenient. 

Chronic  discharge  from  the  ear  should  be  treated  with  mild 
astringents,  very  gently  applied.  Syringing  is  not  nearly  always 
necessary ;  if  done  with  force  it  irritates,  and  may  cause  head- 
ache and  nausea.  Pouring  the  lotion  from  a  teaspoon,  the 
patient  lying  upon  the  other  side  and  turning  over  to  allow  it 
to  run  out,  will  generally  do  better.  Lotions  so  used  should  be 
warm. 

Castile  soap  and  water  ;  lime-water  ;  glycerin  and  rose-water 
(one  part  to  five) ;  and  solution  of  acetate  of  lead,  one  or  two 
grains  in  au  ounce  of  Avater,  will  prove  the  best  washes,  and  suf- 
ficiently strong  to  mitigate,  without  too  suddenly  checking  the 
discharge.  Pure  alcohol  (F.  E.  Weber)  is  sometimes  employed 
for  the  same  purpose.  Bezold  ^  has  found  boracic  acid  very  service- 
able in  suppurative  otitis.  He  washes  out  the  meatus  with  a 
four  per  cent,  solution  of  the  acid,  and  then,  after  drying  the  ear, 
introduces ^neZv/-290t(jfZerecZ  boracic  acid.  The  meatus  is  then  closed 
with  antiseptic  (salicylic,  carbolic,  or  boracic)  cotton ;  which  is 
renewed  as  often  as  it  becomes  moistened  with  the  discharge. 

Deafiiess  (cophosis),  in  greater  or  less  degree,  may  result  from, 
1.  Accumulation  of  wax  in  the  ear ;  2.  Inflammatory  thickening 
of  the  membraua  tympani ;  3.  Obstruction  of  the  Eustachian 
tube ;  4.  Perforation  of  the  tympanic  membrane ;  5.  Destruction 
of  the  osfiicula  of  the  ear;  6.  Paralysis  of  the  auditory  nerve. 
Only  in  case  of  the  last  is  the  patient  unable  to  hear  the  ticking 
of  a  watch  placed  between  the  teeth.  The  effects  of  the  first  two 
are  often  transitory. 

Meniere's  disease  is  the  name  given  (since  1861)  to  an  affection 
in  which  severe  symptoms,  as  giddiness  (labyrinthine  vertigo), 
tinnitus  aiirium,  deafness,  staggering,  often  rotary  movements, 
and  vomiting  follow  lesions  in  the  labyrinth  of  the  ear.  The 
pathology  of  this  disorder  is  not  well  known.  Dr.  Knapp,'-  of  IsTew 
York,  believes  that  there  is  always  either  hemorrhage  or  serous 
or  purulent  exudation  into  the  semicircular  canals.    The  attacks 

1  Boston  Med.  and  Surg.  Journal,  June  24,  1880. 

-  Archives  of  Ophthalmology  and  Otology,  vol.  ii.,  No.  1.  See,  also,  Hinton,  Guy'e 
Hospital  Reports,  vol.  xviii.,  1873. 


848    DISEASES   OF    BRAIN   AND    NERVOUS   SYSTEM. 

are,  however,  not  unfrequently  transitory  and  followed  by  entire 
recovery.  Charcot's  use,  in  all  cases  of  this  affection,  of  large 
doses  of  quinine,  continued  for  weeks  at  a  time,  does  not  appear 
to  me  capable  of  rational  justification;  although  certain  cases 
may,  no  doubt,  be  appropriate  for  nervine  and  tonic  medication. 

APOPLEXY. 

Definition. — Sudden  coma,  produced  neither  by  injury  nor  by 
poison. 

Varieties. ^Some  terms  once  used  have  been  shown  to  be  with- 
out pathological  justification ;  as  serous  apoplexy,  nervous  apo- 
plexy. Good  authority  still  sustains,  however,  the  mention  of 
two  forms  at  least  of  genuine  apoplectic  seizure  :  congestive  and 
hemorrhagic. 

Symptoms.  Congestive  Apoplexy. — Premonitory  symptoms 
often  seen  are,  flushed  appearance  of  the  face  and  eyes,  heat  of 
head,  throbbing  of  the  carotids,  distention  of  the  temporal  arte- 
ries and  jugular  veins ;  constijiation,  languor,  dulness,  drowsi- 
ness ;  dimness  of  sight,  vertigo,  headache.  The  attack  is  marked 
by  sudden  stupor ;  with  slow  and  sometimes  snoring  respiration, 
full  and  slow  pulse,  dusky  or  turgid  appearance  of  the  face.  The 
total  loss  of  perception  may  be  brief,  its  partial  absence  or 
deficiency  continuing  for  some  time.  Slight  convulsive  move- 
ments are  not  uncommon.  Paralysis  of  the  muscles  occurs  only 
for  a  short  time  after  the  attack,  if  this  be  recovered  from. 

Hemorrhagic  Apoplexy. — Generally  no  clear  premonition  is 
given,  the  attack  being  very  sudden ;  a  stroke,  literally.  Uncon- 
sciousness is  complete,  for  some  seconds,  minutes,  or  hours. 
After  this,  general  or  local  paralysis,  most  often  hemiplegia,  is 
left ;  the  mental  powers  also,  in  many  cases,  being  impaired,  at 
least  temporarily.  During  the  coma,  the  breathing  is  commonly 
stertorous,  the  pulse  slow  and  somewhat  full,  the  head  hot,  the 
face  more  or  less  dark  or  flushed.  But  the  fulness  of  the  blood- 
vessels and  heat  of  the  head  are  less,  as  a  rule,  than  in  congestive 
apoplexy. 

Anatomy  and  Pathology. — In  the  congestive  form,  excessive 
cerebral  hypersemia  produces  coma  by  pressure  upon  the  brain ; 
the  extremest  degree  of  which  (vascular  pressure  from  obstruc- 
tion) is  met  with  in  strangulation. 

In  hemorrhagic  apoplexy,  from  the  rupture  of  a  degenerated 
artery,  either  in  the  substance  of  the  cerebrum  or  cerebellum,  in 
the  ventricles,  or  under  the  arachnoid  membrane,  effusion  of 
blood  occurs,  and  a  clot  is  formed.  If  this  be  small,  it  may 
be  gradually  absorbed ;  autopsic  inspection  sometimes  showing 
the  remains  of  such,  where  another  hemorrhage  has  caused 
death. 

Patty  degeneration  of  the  arteries  of  the  brain  has  been  repeat- 
edly, but  not  always  observed.  Embolism  is  asserted  to  have 
sometimes  produced  apoplectic  symptoms ;  but  this,  I  believe, 
must  be  comparatively  rare.     Dr.   Lidell,^  however,  follows  'Nie- 

1  Treatise  on  Apoplexy,  New  York,  1873. 


APOPLEXY. 


349 


Fig.  111. 


Miliary  Aneurisms.    (Hamilton.) 


meycr  in  l)oriovin<;-  the  immediate  cause  of  apoplectic  symptoms 
(whether  produced  by 
congestion,  (edema,  or 
hemorrhage)  to  be  cere- 
bral anieinia  ;  or,  at  least, 
])rivalion  of  oxygenated 
blood  in  tin;  ))rain.  Dv. 
Lidell  has  elaborately  con- 
sidered {Am.  Journ.  of 
Med.  Sciences,  Jan.  and 
July,  1874)  the  clinical 
and  pathological  history 
of  cerebral  thrombosis, 
under  its  three  varieties 
of  origin,  as  traumatic, 
inflammatori/,  and  maras- 
mic.  Of  130  cases,  only 
()  were  traumatic,  80  in- 
flammatory, and  38  ma- 
rasmic,  or  due  to  debili- 
tating influences.  Among 
the  inrtammatory,  facial 
carlnnicle  was  the  most  frequent  cause.  Otitis  and  erysipelas  are 
also  liable  to  the  same  termination.  The  symptoms  of  cerebral 
thrombosis  are  not  always  distinctive,  but  they  differ  from  those 
of  apoplexy  most  of  all  in  the  comparative  slowness  of  their  suc- 
cessive occurrence ;  signs  of  brain  trouble  and  failure  being  at 
last  followed  by  stupor,  often  convulsions  and  paralysis.  Intra- 
cranial aneurism,^  with  rupture  of  the  sac,  is  probably  not  infre- 
quent. Constant  headache,  with  amaurosis,  or  some  form  of 
progressive  paralysis,  will,  when  aneurism  is  present,  generally 
precede  the  apoplexy.  The  basilar  artery  is  (Gouguenheim) 
most  often  affected  ;  next,  the  middle  cerebral ;  then,  the  internal 
carotid.  Intra-crauial  aneurism,  or  sacciform  dilatation  of  some 
of  the  cerebral  vessels  (miliary  aneurisms  of  Charcot  and  Bou- 
chard) will  no  doubt  account  for  a  considerable  number  of  cases 
of  cerebral  hemorrhage.  Atheroma  (fatty  and  calcareous  degen- 
eration and  softening)  may  occur  in  the  arteries  of  the  brain,  as 
well  as  elsewhere.'^  Zenker  insists  that  minute  inter-cranial 
aneurisms  are  due  to  sclerosis  of  the  inner  coat  of  the  cerebral 
arterioles ;  although  this  is  denied  by  Charcot  and  Bouchard.* 
The  parts  of  the  brain  most  liable  to  extravasation  of  blood  are 
(Aitken)  stated  in  this  order  :  1,  corpus  striatum,  thalamus,  and 
hemispheres  above  them ;  2,  corpus  striatum  alone ;  3,  hemi- 
spheres above  the  centrum  ovale ;  4,  thalamus  alone ;  5,  lateral 
lobes  of  cerebellum  ;  6,  mesocephalon  ;  7,  posterior  lobe  of  cere- 
brum ;  8,  before  the  corjius  striatum ;  9,  pons  Varolii ;  10,  middle 
lobe  of  cerebellum;  11,  meninges;  12,  peduncles  and  olivary 
body.     Hemorrhage  into  the  ventricles  of  the  brain  is  shown  by 


1  See  an  article  by  Dr.  J.  H.  Hutchinson,  Penna.  Hospital  Reports^  vol.  ii.,  1869. 

2  Virchow,  Billroth,  Wilks,  and  Moxon  have  shown  that,  in  arteries  generally  athe- 
roma is  the  result  of  a  "sub-iuliammatory  "  process. 

3  Le  Mouvemcnt  Medicale,  Jan.  11,  1S73. 

30 


850   DISEASES   OF   BRAIN   AND   NERVOUS  SYSTEM. 

Sanders^  to  be  more  frequent  than  has  been  generally  supposed. 
He  has  obtained  the  history  of  94  cases  of  2)rimary  intra-ventric- 
ular  hemorrhage.  It  occurs  (proportionately)  oftener  in  young 
and  in  very  old  persons  than  ordinary  cerebral  hemorrhage  ;  its 
onset  is  rapid,  with  profound  coma,  often  convulsions  (not  always 
paralysis),  and  death  usually  in  a  few  hours.     Recovery  from  it 

Fig.  112. 


Hemorrhage  in  Right  Hemisphere  of  Brain. 

is  rare.  The  age  of  the  clot  may  be  ascertained  in  part  by  the 
discovery,  with  the  microscope,  of  hlood-crystaJs :  which  are  not 
found  until  after  seventeen  or  eighteen  days  from  effusion. 

Diagnosis. — Apoplexy  is  to  be  distinguished  from  urcemia, 
alcoholic,  intoxication  (dead  drunkenness),  narcotic  -poisoning  (as 
from  opium),  comjyression  of  the  brain,  or  concussion,  from  blows 
or  falls,  asphyxia  (suffocation),  sunstroke,  catalepsy,  cerebral  hys- 
teria, cerebral  thrombosis,  acute  softening  of  the  brain,  chill  of  per- 
nicious intermittent,  and  spotted  fever  or  "  cerebro-spinal  menin- 
gitis ;"  as  well  as  from  all  forms  of  syncope.  From  ureemic  coma 
it  is  only  to  be  known  by  the  history  of  the  case,  showing  a  renal 
origin  for  the  symptoms,  in  partial  or  total  suppression  of  urine. 
Alcoholic  intoxication  is  revealed  by  the  odor  of  the  breath  and 
the  attendant  circumstances.  Similar  aid  exists  sometimes  in 
cases  of  narcotic  poisoning ;  in  opiate  narcotism,  moreover,  the 
pupil  is  commonly  contracted;  in  that  from  most  other  narcotics, 
it  is  as  firmly  dilated.  Concussion  and  compression  of  the  brain 
are  generally  suggested  by  the  position  of  the  body  (if  found  with- 
out a  history),  and  the  external  marks  of  injury.  Asphyxia  is 
also  usually  pointed  out  by  the  condition  of  things  surrounding 
the  patient. 

In  asphyxia,  blueness  of  the  lips,  and  embarrassment  of  respira- 
tion, with  coldness  of  the  surface,  show  the  origin  to  be  in  the 

1  Amer.  Journal  of  Med.  Sciences,  July,  1881,  p.  85. 


APOPLEXY.  351 

function  of  l)roalhinp:.  Sunstroke  is  attencled  hy  acceleration  and 
feebleness  of  the  pulse,  at  least  in  the  majority  of  cases;  in  some, 
it  is,  identically,  a  congestive  apoplexy.  In  catalepsy,  there  is 
rigidity  of  the  nmscles,  with  rapidity  of  the  pulse,  susceptiljility 
of  the  pupil  to  light,  Ijrief  duration  and  repeated  recurrence  of 
the  attack,  without  any  paralysis.  Cerebral  hysteria  is  rare,  and 
occurs  only  in  females,  whose  previous  disorders  of  the  nervous 
system  will  aid  in  interjjreting  even  coma  as  belonging  to  the 
same  category.  Acute  red  softening  of  the  brain  may  be  very 
dirticult  to  distinguish  from  apoplexy.  It  is,  however,  seldom  if 
ever  so  sudden  in  its  invasion  ;  there  is  more  slobbering  or  tlow 
of  saliva,  and  watering  of  the  eyes ;  and  there  is  not  the  partial 
or  entire  restoration  of  the  faculties  which  an  attack  of  apoplexy, 
not  fatal,  allows  so  often.  Cerebral  thrombosis,  also,  is  more 
gradual  in  the  course  of  its  effects;  with  frontal  headache,  delir- 
ium, dilatation  of  pupils,  swelling,  sometimes  ptosis  (falling)  of 
the  eyelids  ;  often  convulsions.  Thrombosis,  moreover,  is  much 
more  common  in  early  life  than  apoplexy.  Spotted  fever,  or 
"  cerebro-spinal  meningitis," will  be  especially  described,  and  its 
diagnosis  considered,  in  another  place. 

Syncope.,  of  any  form  or  origin,  is  always  marked  by  pallor, 
coldness,  and  loss  of  pulse. 

Prognosis. — This  is  always  alarming  ;  most  so  as  there  is  the 
most  reason  to  believe  that  cerebral  hemorrhage  has  occurred  ; 
and,  therefore,  especially  in  those  advanced  in  life.  In  younger 
subjects,  where  stertor  of  breathing  is  absent,  under  proper  treat- 
ment, congestive  apoplexy  may  be  entirely  recovered  from.  So 
ma}'  a  single  attack  of  the  hemorrhagic  form,  with  a  small  clot 
only,  and  limited,  transient  paralysis.  Each  succeeding  attack 
becomes  more  dangerous  ;  a  third  is  seldom  survived.  The  imme- 
diate danger  connected  with  an  attack  of  apoplexy  should  not  be 
considered  to  have  passed  over  for  ten  days  at  least  after  the 
stroke  itself.  Very  seldom,  indeed,  after  a  hemorrhagic  attack, 
are  the  mental  or  bodily  powers  so  good,  for  the  rest  of  life,  as 
before. 

Causation.— ^j/e  is  the  most  constant  promotive  cause  of  apo- 
plex}^  Cases  are  on  record,  though  of  extreme  rarity,  in  children  ;^ 
between  thirty  and  fifty  it  is  much  more  frequent ;  but  after  fifty 
it  is  one  of  the  most  common  modes  of  death.  Arterial  degen- 
eration is  here  generally  the  occasion  of  the  catastrophe  ;  some 
mental  excitement,  or  bodily  shock  or  eflbrt,  as  danger,  or  joy,  or 
a  few  glasses  of  wine,  or  the  stooping  posture,  or  straining  of 
stool,  causes  a  rupture  of  the  weak  vessel,  and  fatal  cerebral 
hemorrliage.  Neither  sex  seems  to  be  more  liable  to  this  disease 
than  the  other. 

Full  living,  especially  with  alcoholic  intemperance  (even  mod- 
erate), and  indolent  habits,  predispose  to  it  in  a  marked  degree. 
So  does  excessive  brain-work.  Florid,  short-necked,  big-beUied 
people  are  thought  to  be  most  exposed  to  it.  Hypertrophy  of  the 
left  ventricle  of  the  heart  is  believed  to  promote  it.     So  also 

1  One  well-marked  case  has  come  to  my  knowledge  in  a  child.  Hanner,  of  Munich, 
asserts  that  it  occurs  in  young  paticmts  more  often  than  is  commonly  supposed.  See 
Journal  fiir  KimltirkrankluiUbii,  1,  1S71. 


852  DISEASES  or  brain  and  nervous  system. 

(Quain)  degenerative  disease  of  the  right  side  of  the  heart  may 
favor  it,  by  aifording  impediment  to  the  return  of  blood  from  the 
brain  through  the  veins.  After  dinner  and  during  sleep  are  the 
two  most  likely  times  for  the  attack  to  occur. 

Treatment.- — The  younger  the  patient,  and  the  more  vigorous 
his  antecedent  health,  the  more  probable  is  the  existence  of  the 
congestive  form :  and  also,  the  better  the  prospect  of  recovery 
from  hemorrhage  within  the  cranium,  if,  only,  the  effects  of  pres- 
sure be  averted  at  the  time.  If,  then,  in  a  person  under  sixty,  not 
before  of  broken  constitution,  we  find  the  head  hot,  face  turgid 
and  flushed,  the  arteries  and  veins  of  the  neck  and  temples  full, 
the  pulse  strong,  and  the  hearVs  impulse  strong  also  (or  the  heart's 
action  vigorous  though  the  pulse  at  the  wrist  be  oppressed),  hleed.^ 
Watch  the  eftect,  with  the  hand  on  the  pulse.  If  the  breath- 
ing improve,  and  the  pulse  rather  gain  than  lose  in  natural- 
ness and  force,  take  out  ten  or  twelve  ounces.  Should  the 
improvement  progress,  but  a  relapse  into  deeper  stupor  afterwards 
threaten,  either  the  lancet  again,  or  cupping  to  the  nucha,  may 
be  used. 

Older  or  more  doubtful  cases  may  be  treated  tentatively,  with 
cups  alone,  aided  by  mustard -plasters  to  the  legs,  back,  and  epi- 
gastrium in  turn  ;  with  laxative  injections  into  the  rectum  during 
the  attack,  and  saline  purgatives  afterwards.  The  head  should 
be  kept  raised,  and  cooledVith  wet  cloths  until  its  temperature 
becomes  normal.  If  the  hair  be  thick,  it  should  be  cut  very 
short  or  shaved  off  entirely.  In  congestive  apoplexy,  artificial 
resjnration  (Corso),  e.  g.,  hy  Sylvester's  plan,-  has  sometimes  sue 
ceeded  in  restoring  the  patient  to  animation. 

Dr.  Foster,'^  of  Pesth,  has  used  hypodermic  injections  of 
ergotin  ;  with  the  effect,  in  two  cases,  of  considerably  dimin- 
ishing the  coma. 

When,  however,  there  is  reason,  as  usually  is  the  case  in  really 
oZfZ  or  hroken-down  patients,  to  believe  that  strxictural  degeneration^ 
arterial,  or  that  of  ramoUissement,  is  the  source  of  the  attack, 
loss  of  blood  will  be  out  of  place.  It  may  even,  by  exhausting 
the  enfeebled  system,  hasten  death.  Such  cases,  if  they  survive 
the  first  apoplectic  fit,  require  rather  nourishing  diet,  and  some- 
times even  tonics,  to  support  strength,  favor  repair,  and  prolong 
life.  Great  delicacy  of  judgment,  of  course,  is  necessary  in 
deciding,  in  different  cases,  between  these  apparently  so  opposite 
modes  of  treatment.  It  is  right  to  add,  that  the  tendency  of 
medical  opinion,  for  the  last  ten  or  twenty  years,  has  been 
towards  the  curtailment  of  the  use  of  the  lancet  in  apoplexy. 

Where  a  moderately  plethoric  condition  is  present,  and  the 
taking  of  blood,  generally  or  locally,  is  not  decided  upon,  purga- 
tion is  safe  and  likely  to  be  useful.     Jalap,  resina  podophyUi,  or 

1  Dr.  Da  Costa's  expression  is,  "  My  rule  in  all  cases  of  apoplexy  is  to  draw  blood  at 
once ;  but  where  there  is  marked  degeneration  of  the  walls  of  the  arteries,  I  have  never 
had  any  striking  results  from  this  withdrawing  of  pressure  upon  the  brain."  N.  Y. 
Med.  Escord,  Dec.  20,  1879,  p.  582. 

2  See  Asphyxia,  in  a  later  part  of  this  book.  Dr.  Oleborne  reported,  in  the  N.  Y.  Med- 
ical Record,  1876,  a  case  in  which  recovery  ensued,  after  au  hour  and  a  quarter's  perse- 
verance, with  this  method. 

»  Journ.  Medico.-Chirurg.  de  Pesth,  No.  8, 1879. 


SOFTENING    OP    THE    SPINAL,    CORD.  358 

ci-oton  oil,  in  small  doses,  ■v^ill  have  the  advantage  of  convenient 
admiuititration  [F.  135,  13G]. 

INFLAMMATION  OF  THE  SPINAL  MARROW. 

Clinical  Synonyms. — Miielitis,  Spinal  Meningitis. — The  symp- 
toms of  tills  rather  unconmion  atTection  are,  constant  and  severe 
pain  in  the  hack,  increased  hy  motion  ;  sjiasmodic  contractions  or 
rigidity  of  the  muscles,  followed  hy  paralysis,  fever,  constipation 
of  the  howels,  and  retention  of  urine.  Authors  state  that  in 
myelitis  proper,  as  distinguished  from  spinal  arachnitis,  there 
is  no  jiain  nor  muscular  rigidity,  hut  only  paralysis  of  motion  and 
sensation. 

Morbid  Anatomy. — Diffuse  redness  and  opacity  of  the  arach- 
noid, swelling,  and  infiltration  of  the  pia  mater,  with  effusion  of 
serum,  communicating  freely  with  the  cavity  of  the  cranium,  are 
generally  found.  Adhesions  of  the  memhranes from  plastic  lymph 
are  less  common  ;  and  still  less  so,  though  repeatedly  recorded, 
is  suppuration  within  the  arachnoid.  The  dura  mater  is  occasion- 
ally afl'ected  with  inflammation,  and  even  ulceration  and  gangrene, 
commencing  from  without.  The  cord  may  he  reddened  from 
injection  of  its  suhstance,  and  softened  ;  more  rarely,  indurated 
in  parts. 

Treatment. — Local  hleeding,  hy  rather  free  cupping  or  leeching 
along  the  spine,  followed  hy  a  hlister,  and  active  purgation  with 
saline  cathartics,  along  with  entire  rest  of  the  body,  constitute  the 
essential  parts  of  the  treatment  of  simple  acute  inflammation  of 
the  spinal  cord  or  of  its  membranes.  If  the  diagnosis  be  doubt- 
ful, the  practice  must  be  dispropoi-tionately  less  bold  ;  this  is,  of 
course,  a  principle  of  general  application  in  therapeutics. 

Epidemic  cerehro-sjyinal  meningitis  will  be  considered  hereafter, 
as  cerebro-spinal  or  spotted  fever. 

SOFTENING  OF  THE  SPINAL  CORD. 

Rejecting  the  not  uncommon  view  which  refers  ramoUissement 
of  the  cord  in  all  cases  to  inflammation,  1  have  considered  soften- 
ing as  one  of  the  lesions  which  may  be  produced  by  myelitis  or 
si)inal  arachnitis ;  but  would  separate  from  this,  as  in  the  case 
of  cerebral  softening,  the  chronic  atrophic  degeneration  which 
results  in  a  similar  change. 

The  symptoms  of  spinal  softening  are,  first,  numbness  in  the 
extremities,  with  a  sense  of  coldness  ;  pain  in  a  portion  of  the 
hack,  with  local  tendei-ness  on  pressure  ;  then  impaired  mobility, 
and  gradual  loss  of  sensation  in  the  limbs,  or  in  one  limb,  if  only 
one  side  of  the  cord  be  afiected.  When  the  anterior  columns  only 
are  softened,  motor  paralysis  prevails ;  if  the  posterior  columns, 
sensihUity  is  impaired  or  destroyed.  Difficulty  in  walking,  espe- 
cially on  first  rising  in  the  morning,  is  an  early  symptom.  Con- 
tractions and  rigidity  of  muscles  occur  later.  At  a  still  more 
advanced  period,  loss  of  conti'ol  over  the  bladder  and  rectum 
adds  to  the  distress  of  the  patient,  who  is  apt  to  suffer  also  from 
bed-sores,  ulceration  and  sloughing  of  the  parts  upon  which  the 
body  rests  ;  the  system  becoming  gradually  exhausted. 
30*  X 


354    DISEASES   OF   BRAIN   AND   NERVOUS  SYSTEM. 

Prognosis  and  Treatment.— Recovery  is  not  to  be  expected 
from  atrophic  spinal  softening.  The  most  unfavorable  symptoms 
are  decided  paralysis,  involuntary  urination  and  defecation,  with 
alkalinity  of  the  urine.  Treatment  must  be  palliative  and  support- 
ing only.  Passive  exercise  (as  by  riding  in  an  easy  carriage, 
sailing,  or  being  carried)  in  the  open  air  will  be  beneficial ;  and  so 
may  salt  bathing  and  frictions  of  the  surface  of  the  body.  Good 
diet,  appetizing  tonics  (especially  phosphorus),  and  sometimes 
alcoholic  stimulants,  very  carefully  regulated,  may  retard  the 
decline  of  the  patient. 

SPINAL   IRRITATION. 

Under  this  term  (now  discarded  by  many  writers  upon  nosology 
and  diagnosis)  have  been  included  several  aftections  of  different 
pathology,  and  not  always  identical  in  symptoms.  Pain,  tender- 
ness, and  weakness  in  the  back,  with  flying  pains  in  the  chest  and 
sides,  and  sometimes  local  spasms,  without  proof  of  any  decided 
or  progressive  lesion  of  the  cord,  or  either  motor  or  sensorj'  paral- 
ysis, appear  to  be  the  common  features  in  such  cases.  I  think 
a  name  should  be  reserved  for  this  combination,  for  practical  or 
clinical  use ;  although,  as  in  the  case  of  dyspepsia,  and  some  other 
complex  disorders,  the  term  used  may  not  very  well  define  the 
disease.  It  was  first  proposed  in  clinical  medicine  by  Dr.  Brown, 
of  Glasgow,  1828.  Teale  (of  Leeds)  wrote  a  work  upon  it.  Dr. 
W.  A.  Hammond  more  recently  (1870)  reasserted  its  practical 
importance.  He  considers  tenderness  of  the  spine  on  pressure 
an  essential  sign. 

Some  cases  included  in  this  account  are  really  rheumatoid 
(chronic  non-febrile  rheumatic)  affections  of  the  sheaths  of  the 
spinal  nerves ;  others  are  instances  of  myalgia ;  that  is,  mus- 
cular pains  from  weakness  and  exhaustion  in  the  muscles.  Others 
again  display,  with  anaemia  and  general  nervous  debility,  a  real 
irritability  of  the  cord,  shown  by  (hysterical)  spasms  of  some 
muscles,  or  general  convulsions,  under  disturbing  impressions  of 
various  kinds.  Dr.  Benjamin  Lee,^  of  Philadelphia,  has  written 
elaborately  upon  spinal  arthro-chondritis,  or  inflammation  of  one 
or  more  of  the  intervertebral  articulations,  involving  the  inter- 
vertebral fibro-cartilage.  The  typical  symptoms  described  are 
pain,  often  remote ;  muscular  spasm ;  and  permanent  muscular 
contraction. 

Treatment. — The  discovery  of  the  nature  of  the  case  (as  above 
indicated)  is  important.  If,  in  an  otherwise  vigorous  person, 
the  attack  comes  on  after  some  exposure,  the  rheumatoid  con- 
dition is  most  probable ;  and  then  cupping  along  the  spine  will 
do  the  most  good.  Afterwards  counter-irritation,  as  by  croton 
oil,  may  be  used,  and  wearing  flannel  next  the  skin  will  be 
important. 

Myalgic  or  purely  muscular  pains  follow  generally  upon 
fatigue,  and  are  best  cured  by  repose,  aided  by  warm  -frictions, 
as  with  spirit  of  turpentine,  whisky  and  hot  water,  whisky  and 
salt,  etc. 

1  Transactions  of  Medical  Society  of  Pennsylvania,  1868. 


CEREBRAL    AND    .SPINAL    SCLEIIOSIS. 


355 


True  spinal  imtal)ility  {i:  c,  of  the  cord,  not  always  attended 
by  sensitiveness  to  pressure  along  the  back)  is  generally  an 
alVection  of  the  anaemic  and  weak.  Iron  and  other  tonics,  with 
nourishing  food,  salt  hathing,  and  pure  air,  are  demanded  ;  and 
with  these,  mild  counter-irritation  over  the  spine.  Hemlock  or 
Burgundy  pitch  plasters;  repeated  dry  cupping;  painting  with 
tincture  of  iodine,  and  the  limited  use  of  croton  oil  externally, 
are  the  best  measures  of  this  kind  for  such  a  purpose.  Elec- 
tricity may  also  be  serviceable  ;  especially  the  continuous  current. 


CEREBRAL  AND   SPINAL   SCLEROSIS. 

Induration  or  sclerosis  has  now  a  much  larger  place  in  neuro- 
pathology than  was  formerly  awarded  to  it.  By  the  researches 
of  Vulpian,  Charcot,  Frommann,  Turck,  Westphal,  Erb,  Gull, 
Lockhart  Clarke,  Moxon,  Seguin,  Hamilton,  and  others,  it  has 
been  exhaustively  studied.  From  the  protracted  nature  of  the 
maladies  with  which  it  is  connected,  they  being  seldom  fatal  at 
an  early  stage,  the  primary  character  of  the  morbid  process  of 
which  it  is  the  result  is  inferred  rather  than  positively  known. 
The  common  opinion  of  pathologists  is  that  inflammation,  of  a 
subacute  character,  has  to  do  with  its  beginnings. 

Chronic  inflammation  is,  with  some  writers  (as  Bristowe)  synony- 
mous, in  aflections  of  the  nervous  apparatus,  with  sclerosis.  Its 
later  and  most  important  alterations,  at  all  events,  are  atrophic 
and  degenerative. 

When  patches  of  disseminated  spinal  or  cerebral  sclerosis  are 
closely  examined,  they  are  seen,  even  with  the  naked  eye,  to 
have  a  grayish  or  yellowish  gray,  translucent  appearance,  almost 
like  cartilage.     They  are  clearly  defined  from  the  healthy  tissue ; 

Fig.  113. 


A.  Antero-Iateral  Sclerosis.        B.  Posterior  Spinal  Sclerosis.    (Charcot.) 


sometmies  being  slightly  raised  above  it,  in  other  instances  level 
with  It,  or  sunken  below  it.  They  are  roundish,  but  irregular 
and  various  in  form.  When  exposed  to  the  air,  they  become 
somewhat  rose-  or  salmon-colored.  In  consistency,  they  are  firm 
enough   to  be  felt   distinctly  by  the  finger;   to  the  knife,  they 


356    DISEASES    OF    BRAIN   AND    NEItVOUS   SYSTEM. 

present  much  more  resistance  than  the  normal  tissue  of  the 
brain  and  cord.  On  division,  they  show  a  clean  smooth  surface, 
giving  out  a  small  quantity  of  transparent  liquid.  In  a  few 
instances,  in  which  death  from  other  causes  has  allowed  exami- 
nation at  an  early  stage,  they  have  been  found  (Zenker)  soft, 
gelatinous,  or  semi-fluid  in  consistency.  They  vary  in  size  from 
microscopic  minuteness  up  to  the  magnitude  of  a  hazel-nut.  In 
the  cord  they  may  extend  longitudinally  for  a  considerable  distance. 
Microscopically  examined,  the  parts  affected  by  sclerosis  are 
seen  to  have  undergone  structural  changes  of  an  atrophic  charac- 
ter :  consisting  chiefly  in  the  partial  or  total  disappearance  of  the 
medullary  sheath  of  the  nerve-tubules,  while  their  axis-cylinders 
are  still  of  normal  diameter,  or  have  even  become  enlarged ; 
along  with  alterations  in  the  cell-forms  present,  whose  nuclei 
appear  to  be  more  voluminous  than  usual  in  the  outer  zone  of 
the  plaque  or  patch,  but  smaller  and  less  numerous  in  its  central 

Fig.  114. 


Disseminated  Sclerosis  of  Lumbar  Cord.     (Charcot.) 

portion.  At  that  part,  the  trabecular  reticulum  has  disappeared  ; 
bundles  of  substituting  fibrilliie  of  connective  tissue,  axis-cylin- 
ders without  their  medullary  sheaths,  and  more  or  less  thickened 
capillary  vessels,  with  narrowed  calibre,  are  all  that  remain.^ 

Especially  in  disseminated  or  multiple  sclerosis,  the  spots  or 
patches  of  disease  may  be  discriminated  by  the  application  of  a 
solution  of  carmine  in  diluted  aqua  ammoniee.  If  a  portion  of 
the  brain  or  cord  be  hardened  by  maceration  in  a  solution  of 
chromic  acid,  all  of  the  healthy  nerve-cells,  with  their  nuclei,  will 
be  decidedly  stained  by  the  carmine  solution  ;  and  so  will  be  the 
axis-cylinder,  only,  of  the  nerve-filaments.  Sclerosed  nerve-tissue, 
however,  will  not  be  colored  by  the  carmine. 

1  For  a  full  account  of  these  microscopical  appearances,  see  Charcot's  Lectures  on 
Diseases  of  the  Nervous  System,  Lect.  VI.  See  also  an  alsstract  on  the  subject  of 
Sclerosis  by  the  author,  under  Induration,  in  Reynolds'  System  of  Medicine,  American 
edition,  Vol.  I.,  pp.  1009-lOlS. 


C  E  R  E  R  R  A  T.    AND    R  I'  I  N  A  T.    S  C  li  E  R  O  S  I S . 


357 


All  the  anatomical  cleniciats  of  the  nervous  apparatus  may,  in 
some  cases,  be  affected  with  sclerotic  lesion ;  the  capillaries 
(probably)  first ;  afterwards,  the  nerve-cells,  the  nerve-tubules 
with  their  sheaths,  and  the  neuroi::;lia  (intervening  reticular  tissue 
of  K(Uliker  and  Virchow)  ;  as  well  as,  frequently  with  increased 
deposit  in  the  cord,  the  trabecular  connective  tissue. 

Lateral  Spinal  Sclerosis. — This  may  be  either  primary  or 
secondary.  The  latter  follows,  sometimes,  cerebral  disease 
(apoplexy,  or  ramolHssement),  or  else  that  of  the  crura  cerebri, 
pons,  or  medulla  oblongata.  This  constitutes  (Tiirck's  degenera- 
tion) descending  sclerosis  ;  occurring  (from  decussation)  in  the  cord 
on  the  side  opposite  to  that  of  the  brain  lesion. 

Primary  or  idiopathic  lateral  sclerosis  is  symmetrical,  upon  the 
two  sides  of  the  cord.     It  occurs  at  first  and  chiefly  in  the ' '  crossed 

Fig.  115. 


Patch  of  Sclerosis,  a,  Lympliatic  sheath  of  a  vessel  distended  with  fatty 
globules;  b,  a  vessel  transversely  divided,  showing  distention  of  sheath. 
(Charcot). 

pyramidal  columns  "  of  Flechsig,  which  are  posterior  to  the  lateral 
columns  proper,  but  anterior  to  the  direct  cerebellar  columns. 
Extension  may  take  place  horizontall}'^,  so  as  to  include  the 
whole  of  the  posterior  half  of  the  lateral  column,  reaching  the 
posterior  cornua.  The  form  of  the  sclerotic  patches  is  then 
wedge-like  or  triangular  in  transverse  section,  and  they  extend 
to  the  spinal  pia  mater.  In  descending,  secondary  sclerosis,  the 
patches  are  rounded,  and  do  not  reach  the  pia  mater.  Charcot 
has  given  the  appellation  tabes  dorsalis  simsmodica  to  this  disorder ; 
corresponding  with  the  spastic  spinal  paralysis  oi  Erb,  or  tetanoid 
paraplegia  of  Seguin.  It  commences  usually  between  the  thirtieth 
and  fiftieth  years  of  life.     Its  most  frequent  cause  is  exposure  to 


358    DISEASES   OF   BRAIN   AND   NERVOUS   SYSTEM. 

cold  and  wet.  Early  symptoms  are  those  of  great  muscular 
weakness,  the  limbs  dragging  heavily.  Then  follow  twitchings  of 
the  limbs  while  at  rest,  especially  after  exertion  ;  trembling  of 
the  legs  when,  in  sitting,  the  toes  are  made  to  touch  the  floor  ; 
and  increased  tension  of  the  muscles,  causing  a  peculiar  gait  in 
walking.  The  patient  rises  on  his  toes  at  each  step,  so  as  to  be 
constantly  in  danger  of  falling  forward. 

At  this  stage  there  is  a  marked  increase  of  the  tendon-reflex  (see 
remarks  upon  this  later,  under  Locomotor  Ataxy)  of  the  knees, 
when  they  are  struck  in  the  sitting  posture,  one  being  crossed 
over  the  other.  The  same  phenomenon  may  also,  in  such 
patients,  be  manifested  in  the  triceps  and  biceps  muscles  of 
the  arm.  The  ankle-clonus  is  exaggerated  in  the  same  cases. 
No  disturbance  of  sensibility,  or  muscular  atrophy,  occurs; 
nor  is  there  any  symptomatic  trouble  in  the  bladder,  rectum, 
or  sexual  apparatus. 

Slowly  the  disorder  advances,until  it  reaches  complete  paralysis, 
first  of  the  upper  and  then  of  the  lower  limbs ;  with,  also,  i-igid 
contractions  of  their  muscles.  At  last  the  patient  is  unable  to  walk 
or  stand  ;  yet  the  vegetative  functions  of  the  body  are  commonly 
unimpaired.  In  such  a  condition  he  may  live  for  years ;  death 
finally  resulting  from  some  other  disease.  Recovery  is  not  to  be 
expected ;  although  Westphal  and  K.  von  der  Velden^  have  re- 
corded exceptional  cases  of  its  occurrence. 

Bulbo-nuclear  Sclerosis. — This,  the  glosso-lahio-laryngeal  pa- 
ralysis of  Trousseau  (progressive  bulbo-nuclear  paralysis  of 
Kussmaul),  was  first  described  by  Duchenne.  Its  seat  is  in  the 
motor  nuclei  of  the  medulla  oblongata.  Happily  rare,  it  is  one 
of  the  most  terrible  of  all  chronic  diseases.  Beginning  mostly 
after  the  age  of  forty,  generally  in  males,  its  first  symptoms  are 
pain  and  oppression  in  the  neck  and  back  of  the  head,  with  diz- 
ziness and  hesitation  in  speech,  and  slowness  in  mastication. 
Weakness  of  the  lips  ensues ;  the  mouth  falls,  producing  a 
lugubrious  expression.  Swallowing  becomes  difficult,  from  en- 
feeblement  of  the  muscles  of  the  palate,  pharynx,  and  epiglottis  ; 
so  that  choking  is  endangered  in  taking  food.  Dribbling  of  saliva 
is  frequent ;  the  voice  grows  indistinct ;  and  attacks  of  dyspnoea 
occur  from  time  to  time.  Without  impairment  of  general  sensi- 
bility or  of  the  mental  functions,  these  disabilities  all  increase, 
until  it  becomes  imj^ossil^le  for  the  patient  to  take  any  nourish- 
ment. At  last,  death  occurs  from  starvation;  unless  hastened 
by  some  intercurrent  attack,  as  of  pneumonia.  In  not  a  few 
cases,  progressive  atrophy  of  the  muscles,  especially  those  of  the 
tongue,  palate,  and  face,  coincides  with  the  above  symptoms. 
Some  pathologists  (Kussmaul,  Charcot,  Erb)  have  asserted  the 
essential  identity  of  this  disorder  with  'progressive  muscular 
atrophic  paralysis.  Others  (Duchenne,  Eriedreich,  Hammond) 
oppose  this  view. 

After  death,  in  some  cases,  the  unaided  eye  can  perceive  no 
morbid  change  in  the  medulla  oblongata.  In  many  instances, 
however,  diminution  in  bulk  and  alteration  of  consistence,  with 

1  Berliner  Klin.  Wocheuschrift,  Sept.  23, 1878. 


CEREBRAL    AND    SPINAL    SCLEROSIS.         359 

gray  discoloration  in  spots  or-patchcs,  may  be  seen.  Microscopic 
examination  lias  shown  the  characteristic  change  to  be  a  yellow 
pigmentary  dvijcneration  of  the  nuclei  of  the  hypoglossal,  spinal  acces- 
sory, vagus,  and  facial  nerves. 

Multiple  Cerebro-Spinal  Sclerosis.— This  is  the  "sclerose  en 
plaques  (lissrmint'es  "  of  Charcot ;  insular  sclerosis  of  Moxon.  It 
may  occur  in  the  spinal  marrow  alone,  or  in  the  brain  alone ;  but 
most  frequently  both  are  more  or  less  involved  in  its  course. 
Cruveilhier'  mentioned  it  many  years  ago;  Carswell,  Tiirck, 
llokitansk}%  and  Freriehs  partially  described  it ;  but  the  obser- 
vations of  Vulpian  and  Charcot  have  most  definitely  marked  out 
its  present  place  in  pathology. 

It  is  most  connnon  in  women,  between  the  ages  of  twenty 
and  thirty;  but  is  sometimes  met  with  in  still  younger  subjects. 
Hereditary  predisjiosition  is  more  noticeable  in  connection  with 
this  than  with  other  forms  of  sclerotic  disease.  Exposure  to  cold 
or  wet,  and  disturbing  mental  influences,  are  believed  often  to 
have  to  do  with  its  immediate  causation.  Shock  from  physical 
injury,  and  various  acute  disorders,  are  also  thought  to  jDromote 
its  occurrence. 

The  symptoms  of  multiple  sclerosis  are,  so  to  speak,  a  variable 
composite  of  those  of  sclerosis  of  different  parts  of  the  cerebro- 
spinal axis.  Its  first  signs  are  obscure.  Weakness  and  dragging 
of  the  limbs,  pains  in  different  parts  of  the  body,  dizziness  and 
headache,  are  among  the  earliest  of  these.  Afterwards,  symp- 
toms may  present  themselves  which  belong,  in  turn  or  together, 
respectively  to  locomotor  ataxy,  spasmodic  spinal  paralysis,  or 
bulbo-nuclear  sclerosis.  Both  in  its  semeiology  and  in  its  morbid 
anatomy,  this  disease  is  truly  multiple  or  polymorjjhoiis. 

Typical  cases,  nevertheless,  possess  a  combination  of  charac- 
ters tolerabl}^  distinctive  ;  such  as  tremor  accompanying  all  vol- 
untary movements ;  monotony  of  speech, and  a  "scanning  "  artic- 
ulation ;  nystagmus  (rolling  of  the  eyeballs  from  side  to  side); 
amblyopia  (feebleness  or  indistinctness  of  vision)  ;  diplopia 
(double  vision) ;  vertigo  ;  and  apoplectiform  attacks. 

The  volitional  tremor  of  multiple  sclerosis  differs  from  the  con- 
stant trembling  of  paralysis  agitans.  The  head  is  usually  involved 
in  the  shaking  of  multiple  sclerosis ;  seldom  in  that  of  shaking 
palsy.  The  tremor  is  also  smaller,  finer  in  its  vibrations  in 
paralysis  agitans  than  in  nmltiple  sclerosis.  Charcot  refers  the 
causation  of  the  trembling  in  the  last-named  affection  to  the 
persistence  of  many  of  the  axis-cylinders  of  the  spinal  nervc- 
tibres,  with  degeneration  of  their  medullary  substance,  giving 
rise  to  an  imperfect  and  jerking  conduction  of  motor  impulses. 

Erb,  Ordenstein,  Yulpian,  and  Hammond  have  offered  evidence 
in  favor  of  the  opinion  that  tremor  occurs  only  when  some  por- 
tion of  the  brain  (not  the  spinal  marrow  alone)  is  involved  in 
the  disease. 

The  duration  of  cases  of  multiple  sclerosis  is  ordinarily  from 
five  to  ten  years.  If  the  symptoms  in  some  instances  remit  for 
awhile,  they  may  be  expected  to  return,  probably  after  a  short 

1  Atlas  d'Anatomie  Pathologique,  1835,  1842. 


360    DISEASES   OF   BRAIN   AND   NERVOUS  SYSTEM. 

interval.  Yulpian  has  reported  one  case,  in  whicli  a  remission 
lasted  for  three  years. 

Posterior  (or  Postero-lateral)  Spinal  Sclerosis.— This  is  Loco- 
motor ataxy :  an  account  of  which  will  be  given  upon  a  later 
paoje. 

The  treatment  of  all  varieties  of  sclerosis  of  the  nervous  centres 
has  proved,  so  far,  generally  unsatisfactory.  Palliation  of  dis- 
tressing symptoms,  economy  of  vital  power,  and  prolongation  of 
life  by  the  most  favorable  conditions,  seem  to  be  all  that  can  be 
reasonably  looked  for.  Yet  a  justifiable  employment  of  various 
tentative  measures  has  not  been  neglected.  Counter-irritation, 
by  blisters,  issues,  setons,  and  moxas ;  nitrate  of  silver,  arsenic, 
chloride  of  gold,  ergot,  phosphorus,  strychnia,  belladonna,  iodide 
and  bromide  of  potassium,  corrosive  sublimate,  and  chloride  of 
barium;  the  "wet  pack"  (hydropathic  system);  massage;  and 
lastly,  electricity,  have  all  been  tried,  with  but  limited  success 
in  most  instances.  Da  Costa  ^  recommends,  upon  experience, 
administration  of  corrosive  sublimate  in  non-salivating  doses, 
from  an  early  period,  continued  for  months  together.  S.  Weir 
Mitchell  advises  the  use  of  hypodermic  injections  of  morphia, 
alone  or  combined  with  atropia,  for  the  relief  of  suffering.  Mass- 
age and  the  continuous  voltaic  current,  with  occasional  warm  or  hot 
salt  baths,  are  as  promising  as  any  other  measures  of  treatment 
in  these  intractable  affections.  But  hygienic  recommendations 
may  have  an  important  influence,  at  least  in  lengthening  life  and 
making  it  more  tolerable.  Regulation  of  the  diet  (which  should 
be  nourishing,  concentrated,  digestible,  and  sufficiently  varied 
to  promote  appetite);  warmth  of  clothing,  and  protection  from 
undue  exposure,  with  air  and  sunshine  as  often  as  practicable  ; 
a  choice  of  climate  for  residence ;  avoidance  of,  or  extreme 
moderation  in,  sexual  indulgence  ;  occupation,  to  interest,  but 
never  to  weary  or  harass  ;  social,  domestic,  and  all  other  mental 
and  moral  influences  of  the  patient's  environment :  all  these 
may  make  a  difference  of  months,  perhaps  of  years,  in  the  dura- 
tion, and  a  great  mitigation  also  of  the  sufferings,  of  the  most 
incurable  of  diseases. 

PAEALYSIS. 

Varieties. — According  to  the  proximate  cause :  1.  Cerebral  palsy ; 
2.  Spinal;  3.  Reflex  paralysis;  4.  Toxaemic  (e.  g.,  lead  palsy);  5. 
Hysterical  palsy.  According  to  the  extent  of  the  affection :  Facial 
or  other  local  palsy  ;  Hemiplegia  ;  Paraplegia ;  General  paralysis. 
According  to  its  nature:  Motor  (acinesia)  and  Sensory  paralysis 
(anaesthesia). 

Facial  Palsy. — This  is  an  affection  of  the  portio  dura  of  the 
seventh  pair  of  cephalic  nerves,  the  motor  nerve  of  the  face.  It 
occurs  at  any  age,  usually  from  rheumatoid  inflammation  of  the 
sheath  of  the  nerve  at  its  escape  from  the  cranium  through  the 
stylo-mastoid  foramen.  One  side  of  the  face  is  without  change 
of  expression ;  and  the  eye  on  that  side  is  not  closed  (in  severe 

1  N.  Y.  Med.  Record,  April  5, 1879.  " 


PARALYSIS.  361 

cases),  on  account  of  the  paralysis  afTocting  the  orbicMlaris  palpe- 
brarum muscle.     The  tongue  is  not  allected  in  its  movements. 

The  facial  motor  nerve  is  seldom  involved  in  the  much  more 
serious  cases  of  cerebral  palsy.  In  facial  palsy  the  retention  of 
control  over  the  tongue,  while  the  power  over  the  eyelid  is  partly 
or  wholly  lost,  with  the  absence  also  of  severe  cerebral  symp- 
toms, will,  especially  in  a  young  person,  make  the  diagnosis  easy 
as  well  as  important.  The  prognosis  is  generally  of  recovery  in 
a  few  (lays  or  weeks.  The  treatment  of  this  form  of  local  palsy 
may  be  by  repeated  small  blisters  behind  the  ear,  followed, 
when  convalescence  has  begun,  by  some  warm  covering  (cotton 
wadding,  tlauuel,  or  silk)  to  protect  the  part  from  cold. 

Other  Local  Palsies. — Pressure  upon  a  nerve  may  cause  its 
paralysis,  generally  temporary.  I  remember  the  case  of  a  man, 
whose  hand  was  rendered  powerless  for  about  three  weeks  by 
sleeping  all  night  with  his  arm  bent  under  his  head.  Frictions, 
the  endermic  application  of  strychnia,  and  galvanism  were  used 
in  that  case.  Writcr''s  cramp),  or  scrivener's  palsy,  is  the  result 
of  exhaustion  of  certain  muscles  from  overuse.     Its  cure  is  rest. 

Palsy  of  the  optic  nerve  is  designated  as  amaurosis ;  of  the 
sense  of  hearing,  cophosis;  of  taste,  ageustia;  of  smell,  anosmia. 
Except  the  first,  however,  these  terms  are  not  much  used. 

Hemiplegia. — Brain-lesion  is  most  often  the  cause  of  this  affec- 
tion ;  either  an  apoplectic  clot,  a  tumor,  embolism,  or  softening. 
Spinal  disease  may,  however,  produce  it ;  and  some  cases  are, 
by  writers  upon  the  subject,  referred  to  a  peripheral  or  reflex 
origin.  There  may  occur  also,  transiently,  epileptic,  choreic,  and 
hysterical  hemiplegia.  Owing  to  the  decussation  of  the  anterior 
pyramids  of  the  medulla  oljlongata,  lesion  of  one  side  of  the 
brain  produces  paralysis  of  the  other  side.  In  spinal  lesion  the 
palsy  is  usually  on  the  same  side.  Brown-Sequard,  however, 
has  shown  decussation  in  the  cord,  also,  of  the  sensory  nerve- 
filaments. 

Fcrrier,  in  accordance  with  his  experiments  upon  localization 
(see  Part  I.,  Neuro-prnthology),  gives  the  following  summary  state- 
ment : 

"  While  we  cannot  be  quite  certain  of  the  position  or  extent 
of  a  cortical  lesion  causing  a  sudden  and  complete  hemiplegia, 
we  may  take  a  monoplegia  (paralysis  of  one  limb,  or  of  a  few 
muscles  only)  of  the  leg,  or  of  the  arm  and  leg,  as  an  indication 
of  lesion  of  the  upper  extremity  of  the  ascending  convolutions 
close  to  the  longitudinal  fissure  ;  brachial  monoplegia  as  a  sign  of 
lesion  of  the  upper  part  of  the  ascending  frontal  convolution,  or, 
if  the  paralysis  affect  the  hand  more  particularly,  of  the  ascend- 
ing parietal" convolution;  brachio-facial  monoplegia  as  indicating 
lesion  of  the  mid-fronto-parietal  region  ;  while  facial  and  lingual 
monoplegia,  or  this  combined  with  aphasia,  indicates  lesion  of 
the  lower  part  of  the  ascending  frontal  convolution,  where  the 
third  frontal  unites  with  it. " 

Symptoms.— Suddenly,  almost  always,  but  not  in  every  instance 

with  loss  of  consciousness,  the  patient  loses  the  power  of  motion, 

and  more  or  less  of  sensation  on  one  side.     In  complete  cases,  the 

parts  involved  are  the  arm  and  leg,  the  muscles  of  mastication 

31 


362    DISEASES   OF   BRAIN   AND  NERVOUS  SYSTEM. 

(with  the  buccinator),  and  the  half  of  the  tongue.  In  trying  to 
protrude  the  tongue  it  is  pushed  out  towards  the  affected  side  ; 
in  retracting  it,  tlie  reverse  happens ;  that  is,  it  is  drawn  towards 
the  sound  side.  The  palsied  cheek  hangs ;  but  the  eye  can  be 
shut  or  opened  at  will.  Both  eyes  are  apt  to  be  turned  towards 
the  side  not  paralyzed ;  and  the  head  turns  also  towards  that 
side.  The  third,  fifth,  and  ninth  nerves  are  especially  likely  to 
show  implication  by  disturbance  of  the  actions  under  their 
control ;  of  the  fifth,  those  of  the  muscles  already  mentioned, 
as  well  as  of  facial  and  lingual  sensation  ;  of  the  third,  loss  of 
power  to  lift  the  eyelid,  strabismus,  and  dilatation  of  the  pupil ; 
of  the  ninth,  one-sided  movement  of  the  tongue,  affecting  also 
the  speech. 

Hemiplegia  may  be  attended  by  either  rigidity  or  relaxation 
of  the  muscles,  and  the  former  may  be  early  or  late.  Where 
there  is  decided  relaxation  in  cerebral  paralysis,  it  is  probable 
that  white  softening,  or  atrophy  from  thrombosis^  or  embolism 
of  some  of  the  vessels  of  the  brain,  is  the  lesion,  with  or  with- 
out a  clot ;  where  early  rigidity  is  marked,  an  apoplectic  clot 
may  be  inferred.  Late  rigidity  is  probably  due  to  an  atrophic 
state  of  the  muscles — a  '■'■rigor  mortis  in  vitce.''^  Contradictory 
accounts  are  given  by  authorities  as  to  the  susceptibility  to  gal- 
vanic excitation  of  the  muscles  on  the  sound  and  on  the  par- 
alyzed side.  It  is  probable  that  the  loss  of  excitability  of  muscles 
is  in  proportion  to  their  atrophy. 

The  prognosis  in  hemiplegia  depends  greatly  on  the  ascertain- 
ment of  its  causation.  If  it  follow  an  epileptic  fit,  or  attack  of 
chorea,  or  occur  in  an  hysterical  subject,  it  may  be  of  compara- 
tively brief  duration,  ending  in  recovery.  If  an  apoplectic  attack 
precede  it,  or  if  any  lesion  of  the  brain  be  inferred  fi'om  the  his- 
tory of  the  case,  the  prospect  is  bad.  Partial  improvement  may 
occur,  but  not  often  entire  restoration  ;  and  renewed  attacks  or 
"strokes"  are  likely  to  take  place.  A  form  of  hemichorea  (post- 
paralytic chorea)  in  rare  instances  follows  hemiplegia. 

Dr.  S.  Weir  Mitchell  has  made  the  curious  observation^  that, 
in  cerebral  palsy  the  growth  of  the  nails  is  retarded  ;  a  more 
rapid  elongation  of  them  being  therefore  a  prognostic  of  partial 
or  complete  recovery.  In  hysterical  palsy  the  nails  grow  as 
usual. 

Treatment.— Essentially  the  same  principles  are  applicable  to 
this  as  have  been  mentioned  in  connection  with  apoplexy.  The 
younger  the  patient,  the  more  vigorous  his  previous  health,  and 
the  fuller  the  circulation,  the  more  appropriate  will  be  the  gen- 
eral or  local  abstraction  of  blood  to  diminish  pressure  upon  the 
brain.  Where  softening  is  apprehended,  bleeding  should  be 
exceptional.  Epileptic,  choreic,  and  hysterical  hemiplegia  indi- 
cate little  or  no  depletion  as  a  rule.  Eest,  regulation  of  the 
bowels,  counter-irritation  by  dry  cups  to  the  upper  part  of  the 
spine,  and  afterwards  a  blister,  with  frictions,  as  with  brandy 
and  red  pepper,  or  whisky  and  hot  water,  or  salt  and  spirits  to  the 

1  Lidell,  Am.  Journal  of  Med.  Sciences,  April,  1873. 

2  Trans,  of  Phila.  College  of  Physicians,  April,  1871 ;  Phila.  Med.  Times,  June  1, 1872. 


PARALYSIS,  of).'3 

affected  limbs  ;  these  are  measures  of  general  utility.  A  seton 
in  the  back  of  the  neck  is  sometimes  recommended.  As  to  strych- 
nia, it  is  not  safe  where  cerebi'al  or  spinal  irritation  is  likely  to 
exist,  as  near  the  comnlencement  of  most  attacks.  Even  at  a 
late  stage,  it  should  be  used  with  extreme  caution,  watching  its 
effects  [F.  l;57].  Precisely  the  same  statement  may,  upon  the 
best  authority,  be  made  as  to  electricity  in  cerebral  paralysis. 
In  the  liijHtcrical  form,  if  this  last  long,  electricity  may  be  applied 
locally,  with  safety  and  advantage.  In  any  curable  case,  massage 
and  prtssire  exercise  of  the  weak  limbs  will  be  very  useful. 

Paraplegia. — This  is  paralysis  of  both  the  lower  extremities. 
Spinal  disease  or  injury  is  its  source ;  with  or  without  cerebral 
implication  or  complication.  It  may  come  suddenly  or  gradually  ; 
generally  its  beginning,  at  least,  is  sudden.  Keflex  paralysis,  as 
described  by  several  authors,  is  sometunes  paraplegic. 

Symptoms.^ — In  organic  or  spinal  pai-aplegia,  as  well  as  in  the 
reflex  form,  numljness  in  the  feet  and  pain  in  the  back  are  apt  to 
be  early  signs.  The  power  of  motion  is  lessened  or  lost  in  the 
lower  limbs.  The  muscles  may  be  either  relaxed  or  contracted. 
The  lesion  of  the  spinal  marrow,  if  progressive,  is  productive, 
finally,  in  man}^  cases,  of  loss  of  power  over  the  bladder  and 
sphincter  ani.  Bed-sores,  with  deep  ulceration  and  sloughing, 
may  occur  in  protracted  cases. 

Treatment.^When  myelitis  is  believed  to  exist,  at  an  early 
stage,  local  depletion  to  a  moderate  extent,  in  otherwise  good 
subjects,  may  be  advised.  In  any  case,  counter-irritation  (not 
vesication,  in  a  bed-ridden  patient,  unless  he  can  lie  well  on  either 
side),  by  repeated  sinapisms,  or  stimulating  liniments  [F.  138, 
130],  will  be  proper. 

While  inflammation  or  active  irritation  of  the  spinal  cord  is 
made  apparent  by  the  symptoms  (pain,  cramps,  muscular  twitch- 
ings,  or  rigidity)  strychnia  is  not  suitable.  After  these  have  sub- 
sided, it  may  be  given — not  more  at  first  than  the  thirtieth  of  a 
grain  twice  daily.  If  it  produce  jerking  movements  of  the  hands 
or  feet,  or  nervous  restlessness,  or  any  marked  uneasiness,  it 
should  be  suspended.  Electricity  may  be  used,  with  similar 
caution,  in  a  secondary  or  relatively  late  stage  of  paraplegia. 
Moderate  (at  first  very  gentle)  shocks  of  the  interrupted  circuit 
are  preferred. 

Hysterical  Paralysis. — In  females,  this  is  among  the  many 
forms  of  functional  disorder  which  that  strange  and  not  yet 
clearly  defined  disorder,  hysteria,  may  produce.  It  is  diagnos- 
ticated by  the  aid  of  the  histor\^  of  the  patient.  Dr.  Todd  stated 
that,  in  it,  the  affected  limb  (it  is  most  often  hemiplegic)  in  walk- 
ing is  dragged  after  the  other,  as  if  a  dead  weight ;  while  in 
cerebral  heniiplegia  the  palsied  leg  and  foot  are  brought  round  in 
a  curve,  the  body  being  bent  tovvard  the  sound  side  "at  the  time. 
I  am  doubtful  of  the  universality  of  this  sign.  The  palsy  in 
hysterical  paralysis  is,  at  all  events,  incomplete,  and  has  usually 
a  marked  degree  of  numbness  associated  with  it.  Briquet  asserts 
that  it  affects  the  left  side  of  the  body  much  more  often  than  the 
right. 

Treatment. — Tonics,  good  nourishment,  and  change  of  air  (in 


364  DISEASES  or  brain  and  nervous  system. 

a  word,  analeptic  management),  are  needed  in  nearly  all  hyster- 
ical cases.  Tor  the  paralysis  itself,  electricity  has  been  found 
useful.  Mild  shocks  for  a  few  minutes  twice  a  day  may  be  given 
with  the  magneto-electric  apparatus. 

Reflex  Paralysis. — From  the  times  of  Whytt  and  Morgagni, 
occasional  instances  of  palsy  of  motion  or  sensation,  caused  by 
an  injury  at  a  distance  from  the  aifected  parts,  have  been  recorded. 
Since  Stanley's  paper  (1833)  asserting  the  production  of  paralysis, 
sometimes,  by  disease  of  the  kidney,  a  number  of  medical  writers 
have  added  to  the  list  of  supposed  cases  of  "paralysis  without 
apparent  lesion."  Worms,  dysentery,  diarrhoea,  uterine  irrita- 
tion, teething,  and  external  injuries  are  all  thought  to  induce 
reflex  paralysis  in  certain  instances.  Diphtheritic  and  scarlatinal 
palsies  have  by  some  been  placed  in  the  same  category.  The  sim- 
plest and  clearest  cases  are  those  of  wounds  ;  e.  g.,  Morgagni's 
case,  in  which  amaurosis  was  suddenly  produced  by  a  blow  upon 
the  eyebrow,  affecting  the  supra-orbital  nerve.  Lardier^  has 
recorded  the  case  of  a  boy  in  whom  amaurosis  was  connected 
with  caries  of  a  tooth,  the  removal  of  which  was  followed  by 
restoration  of  sight.  I  would  exclude  most  of  the  asserted 
instances  of  visceral  reflex  paralysis. 

The  pathologi/  of  this  form  of  palsy  has  been  a  subject  of  much 
controversy.  To  my  judgment  (after  reading  considerably  upon 
it)  the  best  explanation  is  that  of  Handfield  Jones  and  S.  W. 
Mitchell;  expressed  in  the  term  proposed  by  the  former— "inhib- 
itory action. ' '  Denying,  against  no  matter  what  present  authority, 
the  existence  of  inhibition  or  repression  as  ever  proved  to  be  the 
normal  function  of  any  nerve  (such  as  many  assert  on  the  ground 
of  experiment  in  regard  to  the  pneumogastric),  I  consider  it  most 
reasonable  to  admit  it  here  pathologically.  In  other  words,  a 
morbid  impression,  from  injury  or  disease,  in  one  part  of  the  body, 
being  transmitted  along  a  nerve  in  the  nerve  centre,  overwhelms 
or  paralyzes  it ;  the  effect  being  shown,  of  course,  in  the  parts 
to  which  it  distributes  nervous  branches. 

Treatment. — In  true  reflex  paralysis,  of  short  or  moderate 
duration,  the  removal  of  the  irritant  cause  produces  instant  relief; 
as  in  H.  Jones's  case,  where  strabismus  from  palsy  of  the  exter- 
nal rectus  oculi  muscle  disappeared  after  a  piece  of  dead  bone 
was  extracted  from  a  whitlow  on  the  thumb  ;  or  Lawrence's,  in 
which  blindness  of  one  eye  (of  thirteen  months'  standing)  was 
cured  by  the  extraction  of  a  carious  tooth,  with  a  splinlier  of 
wood  projecting  from  one  of  its  fangs.  When  the  nature  of  the 
case  does  not  admit  of  such  prompt  relief,  if  the  diagnosis  be  clear, 
the  same  indication  remains— to  address  our  remedial  measures 
to  the  seat  or  source  of  peripheral  irritation.  Palliate,  if  we  can- 
not cure,  the  trouble  there,  and  we  will  obtain  palliation,  if  not 
relief,  of  the  reflex  disability.  Electricity  has  proved  signally 
useful  in  the  subsequent  treatment.  This  form  of  disorder  is, 
however,  very  rare. 

Diphtheritic  Paralysis. — After  the  termination  of  an  attack  of 
diphtheria,  commonly  within  three  weeks,  the  muscles  used  in 

1  L.  Union  Medicale,  Dec.  14, 1874. 


PARALYSIS.  oGf) 

swallowing  antl  speaking,  err,  less  often,  those  of  the  upper  and 
lower  limbs,  or  the  sense  of  sight,  may  be  partially  paralyzed. 
Loss  of  sensibility  usually  accompanies  the  loss  of  motor  power. 
This  condition  of  things  may  last  for  weeks  or  even  months,  but 
is  generally  recovered  from.  Whether  the  immediate  cause  of 
the  paralysis  be  the  peripheral  lesion  of  the  nervous  terminations 
(in  the  pharyngeal  and  laryngeal  affection)  or  the  toxeemic  influ- 
ence, upon  the  nerve-centres,  of  the  morbid  poison  of  diphtheria, 
cannot  yet  be  decided.  In  extended  palsy,  as  a  sequela,  the  latter 
is  the  more  probable  explanation. 

Treatment, — Passive  exercise,  stimulating  frictions,  and  elec- 
tricity, sometimes  with  change  of  air,  strychnia  cautiously  given, 
and  sea-bathing,  are  suitable  measures  for  this  affection. 

Syphilitic  Paralysis. — The  most  unequivocal  Instances  of  this 
nature  are  accounted  for  by  periostitis  within  the  cranium,  in- 
volving the  dura  mater,  or  by  nodular  exostosis,  pressing  upon 
the  brain.  The  most  remarkable  fact  connected  with  such  cases 
is  the  recorded  experience  showing  the  prompt  curative  effect 
upon  it  of  iodide  of  potassium  [F.  140].  Obscure  paralysis,  with- 
out apoplectic  symptoms,  and  in  a  syphilitic  constitution,  may  be 
always  tentatively  so  treated,  on  the  basis  of  such  experience. 

Lead  Palsy. —Considerable  time  of  exposure  to  the  influence 
of  lead  is  generally  necessary  to  cause  this.  So  commonly  does 
it  first  affect  the  extensor  muscles  of  the  forearm,  that  the  cog- 
nomen of  "  wrist  drop  "  is  often  applied  to  it.  When  it  lasts  for 
some  weeks,  the  muscles  waste  away.  A  blue  line  is  observed  to 
form  along  the  edge  of  the  gums.  Pain  precedes  the  palsy,  and 
attends  recover}^  of  power.  During  the  attack  the  muscles  have 
their  excitability  by  electricity  considerably  diminished  or  lost. 

Lead  poisoning  sometimes  seriously  (even  fatally)  involves  the 
brain  {encephalopatliia  satuvnina).  Tanquerel,  Desboise,  Eosen- 
stein,  Leidesdorf,  and  others,  have  recorded  cases  in  which  the 
symptoms  were,  amaurosis,  hallucinations  of  vision,  and  epilep- 
toid  convulsions. 

Mostly,  though  after  a  long  time,  lead  x'>alsy  is  recovered  from. 
Iodide  of  potassium  appears  to  act  as  an  eliminant  of  the  lead 
accumulated  in  the  system.  Ergot  is  asserted  by  some  to  be 
curative  also.  Faradaic  electricity  has  been  found  decidedly 
beneficial ;  used  in  moderate  strength  for  a  few  minutes  two  or 
three  times  a  day.  (See  Medical  Electricity^  in  Part  I. ,  Sect.  III. ) 
A  milk  diet  is  asserted  by  M.  Peligot,  an  experienced  glass  man- 
ufecturer,  to  be  preventive  of  lead  poisoning  in  those  exposed 
to  it. 

Mercurial  Palsy  is  occasionally  met  with  in  those  who  work 
with  the  metal.  Mf)stly  tremor  is  a  predominant  symptom. 
Early  withdrawal  from  the  influence  of  the  cause,  and  the  con- 
tinued use  of  the  iodide  of  potassium,  are  the  principal  measures 
of  treatment. 

Paralysis  agitans,  or  shaking  palsy,  is  a  more  or  less  constant 
involuntary  and  uncontrollable  shaking  of  the  hands,  arms  (sel- 
dom the  head),  and  progressively  of  the  whole  body.  Slight  or 
moderate  degrees  of  such  tremor  are  common  enough  from  general 
nervous  debility.  Extreme  cases  evince  the  wreck  of  the  ccrebro- 
31* 


366    DISEASES   OF   BEAIN   AND   NEEVOUS  SYSTEM. 

spinal  system,  and  are  therefore  incurable.  Since  the  study,  by 
Charcot  and  others,  of  disseminated  or  multiple  cerebro-spinal 
sclerosis,  some  cases  are  referred  to  that  affection  which  formerly 
would  have  been  included  as  examples  of  paralysis  agitans.  Two 
kinds  of  tremor  are  described  ;  one  constant  (that  of  paralysis 
agitans),  and  the  other  volitional,  i.  e.,  occurring  only  when  some 
muscular  action  takes  place  under  an  effort  of  the  will.  The  latter 
belongs  to  disseminated  or  multiple  cerebro-spinal  sclerosis.  No 
absolutely  certain  demonstration  of  the  morbid  anatomy  of 
paralysis  agitans  has  yet  been  obtained ;  and  no  especial  treat- 
ment can  be  pointed  out  for  it. 

Spastic  Spinal  Paralysis — Lateral  Spinal  Sclerosis. — This  has 
been  already  sufficiently  considered.  (See  Cerebral  and  Sjnnal 
Sclerosis.) 

Wasting  Palsy  (Cruveilhier's) — Progressive  Muscular  Atrophy. 
— A  few  of  the  muscles  of  one  limb,  or  the  voluntary  muscles  of 
the  whole  body,  may  lose  their  power,  and  then  waste  away 
almost  to  nothing.  The  shoulder  and  the  ball  of  the  thumb 
are  frequent  points  of  commencement  for  the  palsy  and  atrophy. 
Insidious  in  its  approach,  the  affection  may  last  from  six  months 
to  several  years.    It  may  end  in  recovery,  in  permanent  arrest  at 

Fig.  116. 


Advanced  Wasting  Palsy. 

a  certain  stage  of  the  disease,  or  in  death.  Twelve  months  is 
the  earliest  recorded  period  for  the  occurrence  of  a  fatal  end. 
This  is  the  result  always  when  the  trunk  is  invaded.  After 
death,  the  spinal  maiTOW  has  been  examined  in  but  a  few  cases. 
No  lesion  has  been  found  in  most  of  them ;  in  a  certain  number 
it  has.  Dr.  J.  Lockhart  Clarke  in  one  case^  found  the  diameter 
of  the  cord  one-fourth  less  than  the  average.  Joffroy,  Hayem 
and  Charcot  assert  the  coincidence  in  several  instances  of  pro- 
gressive muscular  atrophy  with  degeneration  of  the  anterior  gray 
cornua  of  the  spinal  cord.  Friedreich,  Cohnheim,  and  Lichtheim 
have  reported  cases  where  no  lesion  of  the  cord  or  nerves  was  ascer- 
tained; but,  considering  the  possible  minuteness  of  such  alterations 
under  some  circumstances,  positive  observations  outweigh  the 
negative,  which  may  be  exceptional.  Our  methods  of  inspection 
of  nervous  tissue  are  yet  too  imperfect  for  it  to  be  pronounced 
that  such  an  atrophic  disease  is  ever  independent  of  the  nervous 


1  Brit.  Med.  Journal,  Dec.  7, 1872. 


PARAI.YSIS, 


367 


Fig. 117. 


centres.     It  may  be  the  gawjlia  which  regulate  nutrition  that  are 
most  directl}^  in  fault. 

A  siuiilar  remark  may  be  made  in  regard  to  the  patliology  of 
progressive  muscular  sclerosis, the  pseudo-hypertrophic  muscular 
paralysis  of  Duchenne  ;  the  singularity  of  which  consists  in  the 
Rict  that  while  some  of  the  muscles  are  wasted, 
or  at  least  weakened,  enlargement  afterwards 
occurs,  in  the  same  or  in  other  muscles,'  by 
morbid  proliferation  of  connective-tissue  ele- 
ments. Friedreich  and  Gowers  believe  this 
to  be  an  idiopathic  disease  of  the  muscular 
tissue. 

The  subjects  of  this  affection  are  mostly 
young.  Its  progress  is  gradual  and  not  painful. 
The  muscles  of  the  calves  of  the  legs,  lumbar 
region,  and  buttocks  are  especially  often  in- 
volved. The  affected  muscles  are  not  con- 
tracted at  any  stage.  For  progressive  mus- 
cular atrophy,  the  most  hopeful  treatment  is 
by  means  of  electricity. 

General  Paralysis  of  the  Insane.— Only  a 
minority  of  insane  persons  have  this  affection. 
Difficulty  of  speech  and  general  tremor  char- 
acterize it,  followed  by  the  gradual  loss  of  all 
mental,  muscular,  and  sensory  power.  Delu- 
sions of  an  extravagant  kind  commonly  attend 
it :  whence  some  French  writers  have  called  it 
"folic  ambitieuse."  It  is  incurable.  In  diag- 
nosis. Dr.  Bucknill  has  pointed  out  the  signif- 
icance of  the  loss  of  electro-motor  excitability 
in  the  muscles.  In  pathology,  general  paraly- 
sis, or  paresis^  seems  to  be  connected  with  a 
change  in  the  cortical  substance  of  the  brain. 
Calineil,  who  first  clearly  described  it  (1825 ;  ^ 
Bayle,  1822),  believed  it  to  be  due  to  chronic  Pseudo-hypertrophic 
inflammation  ot  the  brain.  More  probably, 
its  cause  is  a  defect  of  nutrition ;  a  degenera- 
tion ;  whether  or  not  preceded  by  inflammation.  Dr.  Howden, 
of  Montrose,  has  found  granular  degeneration  of  the  nerve-cells 
in  some  cases.^  Granulations  of  the  lining  of  the  ventricles  are 
asserted  by  M.  Joire"'  to  be  peculiar  to  general  paralysis ;  but 
Maudsiey,  Bland  ford.  Shew,  and  Seguin*  have  found  them  in 
cases  of  mania  and  dementia.  Allbutt  has,  by  the  ophthalmo- 
scope, detected  atrophy  of  the  optic  nerves  in  nearly  every  case. 
Ludwig  Meyer,  of  Giittingen  (Virchow's  Archiv,  Aug.,  1873), 
advocates  the  view  that  the  essential  affection  is  a  chronic  inflam- 
mation of  the  brain  and  its  membranes ;  involving  the  minute 


Paralysis, 
towe). 


(Bris- 


1  See  a  careful  analytical  report  of  a  ease  of  this  affection  by  Dr.  W.  Pepper,  Pliila. 
Med.  Times,  .Tune  15th,  1871.  The  researches  of  Lockhart  Clarke  have  made  it  certain 
that  wa.stiiii;  palsy  is  essentially  a  central  disease. 

2  London  Lancet,  July  31,  1SG9,  p.  1.57. 

3  Hullotin  do  I'Acad.  Iniperiale  de  Medecine,  1861. 
*  Amer.  Journal  of  Med.  Sciences,  July,  1871. 


368    DISEASES   OF   BRAIN   AND   NERVOUS  SYSTEM. 

vessels  and  interstitial  material,  not  the  nerve-cells.  Palliative 
treatment  only,  and  that  which  economizes  the  energies  of  the 
system,  can  be  employed  in  this  affection.  For  the  relief  of  the 
occasional  paroxysms  of  excitement,  physostigma  (Calabar  bean) 
has  been  found  rather  particularly  useful. 

Constitutional  syphilis  has  probably  a  causative  relation  to 
some,  but  certainly  not  to  nearly  all  cases  of  general  paralysis. 
When  there  is  room  to  suspect  this,  anti-syphilitic  treatment 
ought  to  be  tried  for  its  relief. 

LOCOMOTOR  ATAXY. 

Though  recognized  in  its  essential  features  by  Sir  Charles  Bell, 
Matthew  Baillie,  Hufeland,  and  others,  this  affection  has  been 
better  known  since  its  especial  study  and  designation  by  Duchenne 
(of  Boulogne)  not  many  years  since.  Dr.  E.  B.  Todd  called  it 
ataxic  paraplegia ;  an  older  name,  especially  in  Germany,  was 
tabes  dorsalis. 

Symptoms. — Pains  generally  first  occur  ;  mostly  in  the  limbs, 
sudden,  variable,  but  often  very  severe  ;  "fulgurant,"  compared 
sometimes  to  toothache  in  the  legs.  Occasionally  they  are  in  the 
face  or  trunk ;  and  commonly  they  are  aggravated  by  pressure, 
as  well  as  by  cold  and  wet.  Strabismus  and  dimness  of  vision 
(amblyopia)  are  apt  to  be  early  symptoms.  Loss  of  sensibility  of 
the  skin,  or  more  deeply  seated,  especially  in  the  feet,  and  after- 
wards in  the  upper  extremities,  follows.  Insensibility  to  pain 
(analgesia)  on  pinching  or  pricking  with  a  needle  occurs  in  many 
cases.  More  rarely,  there  is  local  hypercesthesia^  or  excessive 
tenderness  to  the  touch.  Betention  or  incontinence  of  urine  come 
usually  later ;  spermatorrhoea  often  quite  soon  in  the  case.  Impo- 
tence, in  an  advanced  stage,  is  the  general  rule.  The  bowels  are 
generally  constipated  ;  though  the  patient  may  lose  power  to  con- 
trol the  act  of  defecation.  The  pulse  is  moderately  accelerated. 
The  stomach  is  subject  to  attacks  of  indigestion  and  vomiting. 
Sometimes  a  rheumatoid  affection  of  the  joints  occurs.  This  may 
go  so  far  (Charcot)  as  almost  to  destroy  the  ends  of  the  bones,  at 
the  knee,  shoulder,  or  elbow.  Papular,  or  even  pustular,  eruptions 
are  not  rarely  met  with,  perhaps  increasing  and  remitting  accord- 
ing to  the  severity  of  the  lancinating  pains. 

The  tendon-reflex  disappears  (Westphal)  early  in  locomotor  ataxy. 
By  it  we  mean  the  jerking  of  the  leg  and  foot  upward  and  for- 
ward when,  one  leg  being  crossed  over  the  other  in  a  sitting 
posture,  a  sudden  blow  is  struck  upon  the  tendon  of  the  quadriceps 
femoris  muscle,  at  its  junction  with  the  patella. 

In  a  healthy  person,  this  is  almost  always  observed.  It  is  exag- 
gerated in  lateral  spinal  sclerosis  (spasmodic  spinal  paralysis). 
Analogous  to  it  is  the  ankle-clonus.  If  the  foot  be  flexed  firmly  by 
pressure  upward  on  the  sole,  and  the  tendo  Achillis  be  then  briskly 
tapped,  the  foot  at  once  undergoes  flexion  and  extension,  in  rapid 
succession,  for  a  considerable  number  of  times.  As  this,  like  the 
tendon-reflex,  is  increased  in  cases  of  spastic  spinal  paralysis,  it 
is  to  be  expected  that  it  would  be  diminished  in  locomotor  ataxy ; 
but  the  constancy  of  this  diminution  has  not  beeii  established. 


LOCOMOTOR    ATAXY.  369 

InactwiU/  of  the  pwpil  (Argyll  Robertson)  under  changes  from 
light  to  darkness  and  the  reverse,  is  anotlier  not  infrequent  sign, 
in  locomotor  atax}^,  of  the  diminution  of  retlex  susceptibility. 
The  pui)il  may  be  either  more  or  less  than  usually  contracted 
under  moderate  light ;  Init  it  responds  sluggishly  or  imperfectly 
to  stimulation  of  tlie  contractile  tissues  of  the  iris. 

The  ^K<i/io;/)ioi>iOH/(!  sign  of  this  aifection  is  asynergia  (Bazire), 
i.  e.,  loss  of  co-ordination  of  the  muscular  movements  of  tlie  lower 
limbs.  The  gait,  in  walking,  is  iDisteadi/  and  insecure  ;  the  limbs 
feel  heavy  and  are  easily  fatigued.  Each  step,  in  an  advanced 
case,  is  apt  to  be  made  with  a  sort  of  jerk  forwards  ;  quite  differ- 
ently from  the  slow  and  dragging  movement  of  ordinary  hemi- 
plegic  paralysis.  If  the  patient  shuts  his  eyes,  he  is  likely  to  fall 
down.  A  similar  loss,  of  co-ordination  in  the  ai*ms  and  hands  is 
met  with  not  unfrequently ,  but  to  a  less  extreme  degree.  Although 
Duchenne  asserts  the  persistence  of  muscular  power  without  loss 
in  this  disease,  it  is  almost  certain  (Oppolzer,  AUbutt)  that  it  is 
more  or  less  impaired  from  the  beginning  in  every  case. 

Prognosis. — It  is  a  progressive  disease,  but  of  various  duration  ; 
from  six  months  to  thirty  years ;  average  perhaps  about  seven 
years.     Recovery  is  scarcely  to  be  hoped  for. 

Causation. — This  is  a  disease  of  middle  life,  especially  in  males. 
Obscure  in  its  origin,  and  perhaps,  as  Trousseau  insisted,  con- 
nected with  hereditary  predisposition,  its  main  promotive  causes 
appear  to  be,  exposure  to  cold  and  wet,  depressing  mental  influ- 
ences, and  venereal  excesses,  particularly  self-abuse,  and  syphilis. 

Morbid  Anatomy  and  Pathology. — The  posterior  cohonns  of 
the  spinal  cord  are  characteristically  altered  (^sclerosis  of  Charcot) 
in  locomotor  ataxy.  With  atrophy  and  degeneration  of  the  nerve- 
filaments,  inci'ease  in  the  bulk  of  the  connective  tissues  gives  a 
gray  and  semi-transparent  appearance  to  the  structure ;  espe- 
cially in  the  dorsal  and  lumbar  portions  of  the  cord.  The  posterior 
nerve-roots  (Yulpiau)  are  similarly  affected.  So  are,  also,  the 
cranial  nerves,  at  first  apparently  at  their  peripheral  ends,  and 
progressively  toward  the  centres.  The  5th,  7th,  and  8th  pairs  of 
nerves  are  not  reported  as  having  been  found  subject  to  the  same 
lesions.  Dr.  James  T3^son^  observed,  in  one  case,  softeningof  the 
lumbar  enlargemeni;  of  the  cord,  with  partial  sclerosis  of  the 
antero-lateral  column,  higher  up.  According  to  Erb,  the  sclerotic 
change  probably  begins  in  the  external  hwids  of  the  posterior 
columns,  and  spreads  thence  further;  the  sclerosis  of  the /asacjfh' 
gracilcs  (Goll's  colunms)  being  a  secondary  degeneration.  Simul- 
taneous involvement  of  the  posterior  gray  horns  and  of  certain  por- 
tions of  the  lateral  columns  is  inferred  rather  from  clinical  than 
from  anatomical  evidence.  Examination  of  the  ganglia  and 
nerves  of  the  sympathetic  system  has  seldom  been  made  in  con- 
nection with  this  disease.  Dr.  Gull  believes  the  brain  to  be 
frequently  involved. 

Although  physiological  considerations  suggest  a  cerebellar  as 
well  as  spinal  seat  for  this  disorder,  in  which  loss  of  muscular 
co-ordination  is  so  prominent  a  symptom,  this  view  does  not  seem 

1  Phil,  Med.  Times,  Jan.  31, 1874,  p.  286. 

Y 


370    DISEASES   OF    BEAIN   AND   NERVOUS  SYSTEM. 

to  be  confirmed  as  yet  by  observation.  The  difflculty  would 
appear  to  lie  rather  in  the  perceptive  apparatus  by  which  the 
natural  stimulus  of  the  motor  centres  is  afforded  and  their  func- 
tions maintained. 

Treatment. — Almost  hopeless  of  cure,  the  life  of  a  sufferer  from 
this  malady  may  be  prolonged,  and  his  discomfort  lessened  by  the 
best  hygienic  management,  as  to  food,  atmosphere,  clothing,  and 
rest,  aided  by  tonics,  electricity  (especially  the  constant  current), 
and  perhaps  the  careful  use  of  strychnia,  hypodermically  (Drink- 
ard)  or  by  the  mouth.  Dujardin  Beaumetz^  recommends  phos- 
phorus, in  ^L  grain  doses,  in  almond  oil  (F.  252).  Dr.  S.  Weir 
Mitchell  advises  rest  as  an  important  portion  of  the  treatment.^ 
Althaus'^  asserts  that  he  has  "completely  cured"  two  cases  with 
drachm  doses  of  liquid  extract  of  ergot,  three  times  a  day,  con- 
tinued for  six  or  eight  months.  Dr.  Mitchell  has  confidence  in 
the  advantage  of  rather  large  doses  of  iodide  of  potassium,  for 
alterative  effect.  Debove,  Langeubuch,  Esmarch,  and  Erlen- 
mayer  have  performed  nerve-stretching*  (of  the  sciatic,  radial,  or 
median  nerves)  in  several  cases  of  ataxy ;  with  the  effect  not  only 
of  relieving  the  lancinating  pains,  but  of  at  least  palliating  the 
other  symptoms  of  the  malady. 

ATHETOSIS. 

Hammond  first  applied  this  term  in  1871  to  an  affection  char- 
acterized by  a  constant,  involuntary,  and  more  or  less  regular  move- 
ment  of  thefiyigers  and  toes,  on  one  side  or  both.  As  an  occasional 
phenomenon,  it  had  been  before  noticed,  by  Charcot  in  1853,  and 
by  Heisse  in  1860.  Charcot  regards  it  as  a  variety  of  chorea. 
Gowers  and  McLane  Hamilton  do  not  admit  that  it  requires 
clinical  or  pathological  separation,  as  a  distinct  disease,  from 
other  affections  of  disordered  movement,  chiefly  following  hemi- 
plegia. There  is  no  doubt  that  hemiplegia  has  preceded  athetosis 
in  most  instances  ;  but  not  in  all.^ 

Athetosis  may  be  unilateral,  or  double  (on  both  sides).  If  the 
former,  it  is  nearly  always  upon  the  same  side  with  the  hemiplegia. 
Oulmont  has  written  a  short  treatise**  upon  this  affection.  Cases 
of  it  have  not  been  very  often  reported.^  In  the  autopsy  of  one, 
by  Dr.  Sturges,  of  London  (the  patient  having  died  of  phthisis), 
the  following  appearances  were  observed :  the  whole  right  hemi- 
sphere of  the  brain  was  distinctly  smaller  than  the  left ;  atrophy  of 
some  of  the  convolutions  had  occurred,  especially  those  of  the 
frontal  and  parietal  lobes ;  the  whole  of  the  gray  substance  of  the 
right  corpus  striatum,  and  nearly  all  of  its  white  substance,  was 
destroyed.  In  this  case  the  regular  movements  of  the  thumb 
and  fingers  (alternation  of  clasping  and  pronation  with  supina- 
tion and  extension)  had,  during  life,  occurred  in  the  left  hand 
alone. 

1  Bulletin  G6n.  de  Thgrapeutique,  Jan.  15, 1868,  el  seq. 

2  Am.  Journal  of  Med.  Sciences,  July,  1873. 

3  Ibid.,  October,  1878,  p.  348.  *  Brain,  January,  1881. 
6  See  London  Medical  Record,  March  15,  1879. 

6  Etude  clinique  sur  I'Athetose,  Paris,  1878. 

"  SeeKevue  Med.  Tr.  et  Etrangere,  Jan.,  1879;  and  London  Lancet,  March  15, 1879. 


INFANTILE    PARALYSIS.  371 

INFANTILE   PARALYSIS. 

Under  this  name  is  designated  what  Ilandfield  Jones  would  call 
paresis  (diminution,  withcnit  total  loss,  of  jiower)  of  some  of  the 
nervous  centres,  extending  so  far  as,  in  infancy,  to  arrest  nutri- 
tion, as  well  as  to  abridge  power  in  the  limbs.  Adams  points 
out  the  following  characteristics  of  the  aflection:  1.  The  paral- 
ysis is  usually  partial,  single  muscles  or  groups  of  muscles  only 
being  allected.  2.  Sensation  in  the  paralyzed  parts  is  generally 
perfect,  or  nearly  so.  3.  The  bladder  and  rectum  are  conunonly 
not  distinctly  implicated.  4.  The  paralyzed  muscles  are  not 
rigid  at  any  stage.  Dissipation  or  bad  health  in  the  parents  will 
predispose  to  this  disease  in  children.  No  violent  symptoms 
attend  the  onset  of  the  attack,  although  it  sometimes  comes  on 
quite  suddenly.  There  may  be  moderate  fever ;  in  a  few  cases, 
convulsions.  Nausea  and  vomiting  are  quite  common.  The  sus- 
ceptibility to  Faradaic  electricity  is  less  than  normal.  In  fatal 
cases,  Kosenthal,  Duchenne,  and  Damascina  have  found  an  atro- 
phic malformation  of  the  anterior  cornua  of  the  spinal  cord ; 
with  enlargement  and  thickening  of  the  blood-vessels  ;  the  latter 
being  regarded  as  the  primary  change.^  Spinal  congestion  is 
thought  by  many  observers  (Heine,  Fliess,  Laborde,  RadclifFe) 
to  be  an  early  condition  in  this  disease.  Roth,  of  Bale,  Prevost, 
Vulpian,  and.  others,  have  proved  that  the  typical  lesion  of  this 
affection  is  myelitis  of  the  anterior  horns  of  the  gray  substance 
of  the  cord  (anterior  polmmjelitis).  Barwell  considers  it  charac- 
teristic that  the  loss  of  power  comes  on  suddenly,  without  other 
premonitory  or  attendant  symptoms.  But,  since  paralysis  does 
actually  occur  during  infancy,  sometimes  with  and  sometimes 
without  evidences  of  spinal  congestion,  there  is  need  of  some 
further  addition  to  our  terminology  to  make  clear  the  discrimina- 
tion among  such  cases.  {Lancet^  Feb.  24,  1872.)  Duchenne  con- 
siders that  a  disorder  identical  with  "atrophic  paralysis  of  youth  " 
may  occur  even  as  late  as  forty-five  years  of  age.  Anton  Frey 
also  refers  to  a  "temporary  paralysis"  of  adults,  similar  to  that 
of  infants,  consisting  in  acute  myelitis  of  the  anterior  cornua  of 
the  cord.  The  attack,  in  adults,  is  described  as  commencing 
with  feverishness,  delirium,  deafness,  and  sometimes  convulsions. 
Generally  its  duration  is  but  one  or  two  months ;  if  more  xjro- 
longed,  the  prognosis  becomes  unfavorable.  Mostly,  with  care, 
this  affection  in  infants  tends  to  recovery.  But  want  of  knowledge 
or  of  attention  may  allow  deformity  to  result  from  it;  especially 
club-foot.  "  Talipes  equinus  "  (in  which  the  heel  will  not  touch 
tlie  ground),  says  Dr.  Taylor,'^  "is  the  first,  and  simplest,  and 
most  natural  sequence  of  the  paralysis — the  weight  of  the  foot 
being  all  that  is  necessary  to  produce  it — and  no  other  form  of 
talipes  is  likely  to  occur  while  the  patient  lies  in  bed.  The  bend- 
ing of  the  ankle  outward  (talipes  varus)  is  the  result  of  weight 
on  a  foot  with  a  shortened  tendo-Achillis ;  bending  inwards 
(talipes  valgus)  of  the  ankle  is  the  result  of  weight  partially 
overcoming  the  gastrocnemius,  soleus,  etc.,  and  talipes  calcaneus 


1  Centralblatt  f.  d.  Med.  Wisensschaften,  No.  11,  1872. 

2  Infantile  Paralysis,  p.  83. 


372    DISEASES    OF   BRAIN    AND    NERVOUS   SYSTEM. 

(where  the  toes  are  raised  so  as  to  be  unable  to  touch  the  ground 
at  the  same  time  with  the  heel)  of  weight  entirely  overcoming 
those  muscles."  The  author  just  quoted  concludes,  from  special 
experience,  that  all  such  deformities  are  preventable,  by  proper 
care  as  to  the  position  and  use  of  the  limbs  and  muscles  of  all 
parts  of  the  body  during  the  paralytic  or  paretic  state.  The 
treatment  of  club-foot  is  a  subject  for  surgical  treatises. '^ 

In  some  cases  fatt}^  degeneration  of  the  muscles  takes  place  to 
such  an  extent  as  to  render  the  case  almost  or  quite  incurable. 
Brodie  observed  that  a  case  is  likely  to  recover,  in  which,  when 
the  child  is  lying  on  the  back,  there  is  power  to  draw  the  limbs 
up  by  flexing  the  thigh  towards  the  body. 

Treatment  of  infantile  paralysis  should  consist  of  general 
recuperative  management,  including  tonics  (strychnia  in  some 
cases,  with  caution)  and  cod-liver  oil,  salt  bathing,  passive  exercise 
of  the  affected  limbs,  and  galvanism  ;  especially  the  constant  cur- 
rent. The  latter  must  be  very  carefully  conducted  in  children. 
Local  application  of  heat  is  advised  by  Drs.  Taylor  and  Hammond. 
The  former  prefers  dry  heat  ;  seating  the  child  before  a  fire  and 
thrusting  its  legs  through  a  screen,  so  as  to  be  thoroughly  warmed 
for  hours  together.  Dr.  Hammond  immerses  the  paralyzed  limb 
in  hot  water  at  140°-160°.  The  hot  sancZ-bath  might  be  employed. 
Dr.  Dio  Lewis  has  proposed  for  analogous  cases  a  siin-hath.  Dr. 
Jacobi^  recommends  small  doses  of  ergot,  internally,  in  the  early 
stage  of  the  disease,  when  spinal  congestion  is  believed  to  exist. 
This  practice  is  now  followed  by  many  practitioners. 

EPILEPSY. 

Definition. — Periodical  convulsions,  with  unconsciousness  dur- 
ing the  attack. 

Varieties. —  Grand  mal  said  petit  vial  of  the  Erench  ;  the  latter 
is  the  eclampsia  minor  of  some  writers  ;  in  which  unconsciousness 
occurs  with  scarcely  any  convulsion.  The  term  "  Jacksonian 
epilepsy"  (after  Hughlings-Jackson,  who  has  best  described  it)'* 
has  been  applied  to  unilateral  or  partial  epilei^tic  convulsions ; 
which  may  sometimes  involve  only  a  small  group  of  muscles,  as 
those  of  one  side  of  the  face,  one  hand,  or  one  foot.  Often,  how- 
ever, these  are  followed,  in  time,  by  the  more  usual  form  of  attack. 

Symptoms. — Premonition  occurs  in  a  minority  of  cases  before  a 
seizure  ;  headache,  dizziness,  terror,  spectral  illusions,  or  the 
epileptic  aura.  This  is  a  creeping  or  blowing  sensation,  like  that 
of  a  current  of  air  or  stream  of  water,  beginning  in  a  hand  or 
foot,  and  extending  toward  the  trunk.  It  (if  it  occur)  imme- 
diately precedes  the  paroxysm.  Then,  sometimes  with  a  scream, 
the  patient  falls  down,  and  is  violently  convulsed.  Foaming  at 
the  mouth,  grinding  of  the  teeth  and  biting  of  the  tongue  are 
common  ;  the  face  is  flushed,  the  eyeballs  roll,  the  pupils  are 
unaffected  by  light,  sometimes  vomiting  or  involuntary  urination 
or  defecation  takes  place  •,  and  respiration  may  be  very  laborious. 

1  Adhesive  plaster  has  been  successively  used  for  gradually  rectifying  congenital  club- 
foot, in  early  infaucy. 

2  N.  Y.  Medical  Record,  Oct.  1,  1870. 

3 Reynolds'  System  of  Medicine,  American  edition,  Vol.  I.,  p.  72. 


EPILEPSY.  373 

Epilepsy  is  somclimos  counterfeited.  Among  the  best  tests  for 
a  genuine  case  (I)clasiauve,  Trousseau)  is  a  deadly  pallor,  inime- 
dvately  preceding  the  fall  of  the  patient  in  the  attack.'  Iluppert 
(Virchow's  Archiv,  LIX.,  ?>  and  4)  asserts  that  albundnuria  is  a 
constant  concomitant  of  epileptic  attacks. 

The  fit  lasts  on  an  average  from  five  to  ten  minutes.  The 
interval  between  the  attacks  may  be  from  several  months  down 
to  a  few  hours.  Old  cases  may  have  two  or  three  paroxysms 
daily.     Tliey  vary  much  even  in  the  same  individual. 

The  condition  after  the  attack  is  various.  Generally,  drowsi- 
ness or  deep  sleep  follows  it ;  or  headache,  debility,  ordelirium  ; 
sometimes  maniacal  frenzy.  Homicide  has  been  committed  in 
this  state ;  for  which,  of  course,  the  person  is  not  criminally 
responsible. 

Anatomy  and  Pathology.— Epilepsy  is  not  often  the  immediate 
cause  of  death.  Autopsies  of  epileptics  (Schrceder  van  der  Kolk) 
have  shown  changrs.  especially  in  the  pons  and  medulla  oblon- 
gata ;  dilatation  of  the  blood-vessels  and  extravasations  of  blood 
being  prominent.  Exaggeration  of  reflex  motor  excitability, 
with  loss  of  the  controlling  power  of  the  braiu  over  the  spinal 
axis,  would  seem  to  be  part,  at  least,  of  the  morbid  condition. 
Marshall  Hall's  idea  of  "trachelismus,"  or  temporary  partial 
asphyxia  from  spasm  of  the  muscles  of  the  neck,  has  been 
exploded.  Brown-Srquard's  opinion  of  the  importance  of  the 
aura,  as  indicating  a  peripheral  irritation  at  its  seat,  has,  after 
causing  the  tentative  amputation  of  a  few  limbs,  suffered  the 
same  fate.  Perhaps  as  near  an  approach  as  can  be  now  had  to 
a  true  statement  of  the  pathological  nature  of  epilepsy  is  that  of 
Hughlings-Jackson  :  that  it  is  the  consequence  of  "an  irregular 
discharge  of  nerve-force  occurriiig  in  any  part  of  the  gray  mat- 
ter of  the  brain  or  spinal  cord." 

Diagnosis. — From  hysterical  convulsions,  which  also  may  be 
periodical  and  violent,  those  of  epilepsy  are  distinguished  by  the 
total  loss  of  consciousness — which  is  partially  retained  during 
the  hysterical  paroxysm.  Curability  belongs  much  more  to  the 
latter  than  to  tlie  epileptic  disease. 

Prognosis.  —  Few  cases  of  genuine  epilepsy  recover.  The 
younger  the  patient,  and  the  longer  the  interval,  the  more  hope. 
Life  may  last  indefinitely  with  the  disease.  Gradually,  in  most 
cases,  the  mental  faculties  are  impaired.  Yet  several  great  men 
have  been  epileptic:  CiBsar,  Mahomet,  Petrarch,  Newton,  Peter 
the  Great,  Napoleon,  Byron.  Canon  Liddou  maintains  the  prob- 
ability that  the  Apostle  Paul  was  subject  to  epileptic  attacks. 

Causes. — Hereditary  transmission  of  this  disease  is  common. 
Intemperance,  venereal  excess  and  self-abuse,  blows  on  the  head, 
and  fright,  are  among  the  most  frequent  exciting  causes. 

Treatment. — During  the  paroxysm,  when  habitual,  little  or 
nothing  is  to  be  done.  Place  the  patient  so  that  he  cannot  strike 
his  head  or  limbs  against  anything  hard ;  loosen  the  clothing 
about  the  neck  to  favor  free  resj^iration  and  circulation ;  and 
insure  fresh  air  about  the  patient ;   that  is  all.     An  occasional 

1 C.  B.  Radcliife ;  Croonian  Lecture,  Lancet,  April  12,  1873. 

32 


374    DISEASES   OF   BRAIN  AND  NERVOUS  SYSTEM. 

convulsion  requires  treatment  ;  of  that  more  will  be  said  here- 
after.    (See  Convulsions.) 

To  break  up  the  recurrence  of  the  fits  is  the  problem,  for 
which  a  vast  number  of  remedies  have  been  tried  in  vain.  To 
name  them  would  be  to  go  over  almost  half  the  materia  medica. 
Prominent,  since  nitrate  of  silver  was  abandoned  as  useless  in 
this  disease,  have  been  belladonna,  arsenic,  valerianate  of  zinc, 
digitalis,  and  bromide  of  potassium.  I  have  known  valerianate 
of  zinc  to  postpone  the  paroxysm  for  considerable  periods.  Begin- 
ning with  one  grain  twice  daily,  it  may  be  gradually  increased  to 
three  or  four  times  that  amount.  A  case  of  recovery  occurred 
under  my  knowledge  in  which  rather  large  doses  of  digitalis 
were  persevered  in  for  several  months.  Bromide  of  potassium'^ 
is  now  the  favorite  medicine  with  many ;  upon  the  evidence  that 
it  is  a  direct  sedative  to  the  excito-motor  susceptibility  of  the 
medulla  oblongata  and  other  nerve-centres.  From  ten  to  twenty 
or  thirty  grains,  twice  or  thrice  daily,  may  be  given,  and  continued 
for  an  indefinite  length  of  time.  Dr.  Echeverria  found  it  power- 
less in  104  out  of  486  cases. ^  Bromide  of  ammonium  (dose  10 
grains)  is  spoken  favorably  of  by  some  who  have  used  it.  Bro- 
mide of  arsenic  is  the  favorite  remedy  with  Dr.  Clemens,  of  Frank- 
fort-on-the-Main.  {London  Med.  Becord,  Feb.  15,  1877.)  Dr. 
Hammond,^  latterly,  prefers  bromine  itself  (Bromine,  5j  *?  water, 
fgviij  ;  dose  a  teaspoonful,  diluted).  Bannister,*  Spitzka,  Jewell, 
and  others,  have  observed  that  the  arrest  of  epileptic  convul- 
sions by  bromides  is,  not  unfrequently,  followed  by  furious 
mania.  This  would  suggest  moderation  in  the  use  of  the  rem- 
edy ;  especially  after  its  controlling  influence  has  been  shown. 
Combining  quinine  with  bromides  (L.  Carter  Gray)  has  been 
found  beneficial.  Strychnia  is  lauded  by  AV alter  Tyrrell,  of  Lon- 
don. Dr.  Weidener,  of  Jena,  reports  the  cure  of  a„case  by  the 
hydrate  of  chloral,  given  in  full  doses  shortly  before  the  times 
of  the  expected  paroxysms.  Drs.  Echeverria  and  MacDonald 
have  found  coniwn  to  act  beneficially.^  Dr.  Pollock,®  of  Charing- 
Cross  Hospital,  cured  one  case,  which  had  resisted  bromide  of 
potassium,  with  half-drachm  doses  of  tincture  of  assafoetida  three 
times  a  day.  Many  reports  have  been  made  of  success  in  ward- 
ing off  epileptic  attacks  by  inhalation  of  nitrite  of  amyl.  Fr-om 
two  to  five  drops  may  be  used  at  a  time.  Nitro-glycerin  has 
recently  been  so  employed  (as  well  as  for  angina  'pectoris) ;  one  or 
two  drops  of  a  one  per  cent,  solution  in  alcohol.  So  simple  an 
expedient  as  pulhng  the  great  toe  forcibly,  is  said  (Brown- 
Sequard)  to  often  arrest  an  attack. 

General  roborant  treatment  may  sometimes  contribute  to  the 
good  efiect  of  special  nervine  remedies.     Cod-liver  oil  was  found 

1  In  this  country,  at  least,  the  introduction  of  hromide  of  potassium  as  an  anti-epilep- 
tic may  be  credited  to  Dr.  C.  E.  Brown-Sijquard.  It  was  first  used  in  medical  practice 
by  Dr.  Williams,  in  England,  for  treatment  of  enlargement  of  the  spleen. 

2  Philadelphia  Med.  Times,  Nov.  23,  1872. 

3  N.  Y.  Med.  Record,  .July  2,  1881,  p.  21.  i  Ibid.,  p.  18. 

6  Philadelphia  Med.  Times,  April  15, 1871.  The  preparation  used  was,  in  some  cases, 
the  English  suceus  conii  (from  the  green  fruit),  in 3^  ounce  doses  or  more;  in  others, 
Squibb's  fluid  extract,  from  the  fresh  unripe  fruits,  in  thirty  minim  doses. 

«  Lancet,  August  21,  1869. 


CATAT.EPSY.  375 

to  do  so  in  a  nitirked  instance  by  Dr.  Fairbaira,'  of  Brooklyn.  W. 
Pepper  advises  continued  rest  in  bed. 

Several  instances  are  reported'  of  benefit  from  nerve-stretching 
(median  and  ulnar  nerves)  in  epilepsy. 

Hambursin'  has  recorded  the  cure  of  six  cases  of  long  standing 
by  the  continuous  use  of  large  doses  (ten  drops  twice  daily,  grad- 
ually increased  to  sixty  or  a  hundred  drops)  of  tincture  of  coc- 
c^dus  Indicus,  Dujardin  Beaumetz  and  Planat  also  recommend 
it.  Gowers  and  Uamskill  have  tried  picrotoxin  (active  principle 
of  cocculus  Indicus)  without  satisfactory  results.  Gowers  found 
cannabis  Indica  to  do  good  in  a  few  inveterate  cases ;  and  some 
such  also  had  the  fits  arrested  by  borax,  ten  or  fifteen  grains 
thrice  daily,  continued  for  a  considerable  time.  Hypodermic 
injection  of  apomorphia  (j^t^  grain)  will  (diort  an  epileptic  attack, 
with  some  tendency  to  prolong  the  interval  before  its  recur- 
rence. 

Self-management  is  very  important  to  the  epileptic.  Temper- 
ance, with  nutritious  diet,  as  the  disease  is  one  of  asthenia,  is 
necessar3^  Regularity  of  the  evacuation  of  the  bowels  is  a  sine 
qna  non.  Abundant  exercise  in  the  open  air,  short  of  exhaustion, 
often  does  good ;  systematic  gymnastics  have  even  cured  some 
cases.  They  are  worth  trying  always.  Avoidance  of,  or  the 
extremest  moderation  in,  sexual  intei'course  must  be  insisted 
upon.  Self-abuse  will  make  recovery  impossible.  Tobacco  ought 
not  to  be  used,  unless  by  smoking  only  a  single  pipe  or  a  segar  or 
two  in  the  day.  Coffee  has  not  been  generally  recommended ; 
but  Dr.  Echeverria,  on  the  basis  of  extensive  experience,  asserts 
that  coffee  is  beneficial  to  epileptics. 

It  has  been  already  implied  that  tracheotomy,  suggested  by 
Marshall  Hall,  and  amputation  of  the  limb  in  which  Vhe  aura  is 
felt,  are  useless  although  severe  measures  in  epilepsy.* 

A  seton  kept  in  the  back  of  the  neck  is  well  worth  trying  in 
every  case.     I  have  known  it  to  promote  recovery. 


CATALEPSY. 

This  is  a  periodical  disease,  in  which  the  attack  is  marked  by 
unconsciousness,  and  fixed  rigidity  of  all  or  many  of  the  volun- 
tary muscles.  It  is  rare.  The  attack  generally  lasts  but  a  few 
minutes.  Sometimes,  in  lunatics,  a  semi-cataleptic  state  of  the 
muscles  is  permanent. 

I  am  not  aware  of  any  special  treatment  appropriate  for  this 
aftection.  Management  like  that  suitable  for  the  epileptic  will 
be  in  place  also  in  catalepsy.  Both  are  now  so  well  understood 
to  be  asthenic  disorders,  with  impaired  hcematosis  (blood-mak- 
ing) as  an  important  element,  that  all  reducing  measures  are 
properly  omitted  in  their  treatment.  This  must  be  essentially 
tonic  and  analeptic  or  restorative. 

1  N.  Y.  Med.  Record,  Dec.  11,  1880,  p.  671. 

2  Le  Progr^s  Medical,  Feb.  5,  1881. 

s  Bull,  de  I'Acadeinie  Eoyale  de  Med.  de  Belgique,  No.  2,  1880. 

■»  Another  operation,  cli/orUlccfonu/,  practised  by  Baker  Brown,  of  London,  in  certaia 
cases  in  females,  has  not  met  with  favor  in  the  profession. 


376    DISEASES    OF    BRAIN    AND    NERVOUS   SYSTEM, 


HEATSTROKE. 

Synonyms. — Sunstroke;  Coup  de  Soleil;  Insolatio.  Two  forms 
of  heatstroke  undoubtedly  occur.  In  one  the  direct  rays  of  the 
sun  upon  the  head  induce  cerebral  congestion;  in  the  other  exces- 
sive heat,  often  not  under  the  immediate  influence  of  the  sun, 
affects  the  whole  system  with  prostration,  apparently  from  a  hlood- 
change;  the  chemical  operations  of  the  economy  being  modified 
by  heat  in  a  manner  incompatible  with  the  vitality  of  the  blood. 
Nerve  and  muscle-tissue  are  at  the  same  time  impaired.  After 
death,  Arndt  has  found  the  large  veins  generally  distended  with 
uncoagulated  blood ;  the  heart  contracted,  the  brain,  liver,  and 
kidneys  anaemic  but  swollen  with  oedematous  effusion. 

Symptoms. — G-enuine  swistroke  is  commonly  sudden.  Falling 
unconscious,  the  head  is  very  hot,  the  temporal  arteries  distended; 
the  breathing  is  apt  to  be  stertorous  (snoring),  the  pulse  full,  gen- 
erally rapid,  but  in  a  few  instances  slow.  In  severe  cases  convul- 
sions may  precede  death. 

In  heatstroke  of  the  second  variety  (more  common  than  the 
first),  almost  equal  suddenness  marks  the  attack.  There  is, 
however,  no  excessive  heat  in  the  head;  the  pulse  is  rapid  and 
weak  ;  unconsciousness  is  less  complete,  and  without  stertor  of 
the  breathing;  the  whole  condition  resembles  syncope  rather 
than  apoplexy. 

Causation. — It  is  remarkable  that  few  cases  of  heatstroke  occur 
in  the  country  among  farm  laborers,  and  very  few  at  sea,  even  in 
the  tropics.  Large  cities  afford  nearly  all  the  cases.  In  'New  York 
over  800  cases  have  occurred  in  a  single  week  (1868).  This  looks 
as  if  the  atmosphere  had  much  to  do  with  predisposing  to  it,  at 
least  by  deteriorating  the  blood  and  lowering  the  resistance  of  the 
vital  energy.  In  tropical  climates  the  attack  often  occurs  at  night. 

It  is  almost  always,  in  the  case  of  heat-exhaustion^  those  who 
have  been  fatigued  by  exertion  in  the  sun  or  shade  who  are  over- 
come. Drinking  largely  of  cold  water  when  thus  exhausted  in- 
creases the  danger.  Intemperate  persons  are  particularly  liable 
to  heatstroke. 

Treatment. — For  heat-apoplexy^  cupping  or  lee.ching  the  back 
of  the  neck  or  behind  the  ears  should  generally  be  the  first 
remedy,  after  the  application  of  ice  or  iced  water  freely  to  the 
head.  The  head  and  shoulders  should  be  kept  raised.  A  pur- 
gative enema  should  also  be  administered,  and  sinapisms  applied 
to  the  lower  limbs. 

Heat-exhaustion  requires  quite  different  treatment,  in  part  at 
least.  Cold  water  or  ice  should  be  applied  to  the  head  and  body, 
and  then  sinapisms  to  the  spine,  epigastrium,  and  limbs,  in  turn. 
First  cool  the  blood,  and  then  excite  physiological  stimulation. 
Local  depletion  should  be  avoided.  If  syncopal  symptoms  be 
decided,  ammonia  may  be  for  a  few  moments  applied  to  the  nos- 
trils, and,  if  the  patient  can  swallow,  aromatic  spirits  of  ammonia 
may  be  given  by  the  mouth,  10  drops  every  fifteen  minutes  at 
first,  gradually  increasing  the  interval.  Mixed  cases  of  course 
occur,  demanding  an  intermediate  or  composite  treatment.  A. 
R.  Hall,  of  India,  has  found  the  utmost  benefit  from  the  hypo- 


INSOMNIA.  377 

dermic  injection  of  sulphate  of  quinia  in  heatstroke.'  Brown- 
Sdquard  assorts  the  aduul  cautery,  with  a  liot  iron  momentarily 
applied,  to  be  very  serviceable. 

INSOMNIA. 
Definition. — Morbid  wakefulness  ;  impossibility  of  sleep. 
Causation. —  Apart  from  pain,  or  severe  acute  disease  affecting 
the  brain  (as  delirium  tremens),  insomnia  may  be  brought  on  l)y 
intense  or  prolonged  mental  labor  or  emotional  excitement.  Ex- 
cessive use  of  strong  coffee  or  tea,  or  belladonna,  stramonium,  or 
cannabis  indica,  may  produce  it. 

Pathology. — Only  within  a  comparatively  recent  period  (Dur- 
ham, Hammond)  has  the  correct  view  been  adopted,  that  during 
sleep  the  arterial  circulation  of  the  brain  is  at  its  minimum.  In 
sleeplessness  the  most  certain  error  loci  is  an  erethism  (morbid 
erectility)  of  the  cerebral  arteries,  -which  keeps  their  circulation 
full  and  prevents  sleep.  It  is  not  possible  to  be  sure  that  this 
is  all,  as  the  precise  nature  of  brain-action  and  nerve-force  is 
unknown.     But  this  furnishes  a  basis  for  rational  management. 

Treatment. — This  must  vary  with  the  cause.  The  overworked 
brain  of  the  professional,  literary,  or  business  man  must  be  with- 
drawn from  his  employment.  Irregularity  of  the  circulation 
dependent  upon  general  debility  must  be  met  by  tonics  and 
generous  diet.  Accumulation  in  the  head  must  be  diminished 
by  such  physical  exercise  as  the  strength  will  bear.  Decided 
cerebral  exhaustion  is  apt  to  be  attended  by  such  loss  of  nerve- 
force  as  will  forbid  much  effort  of  any  kind  ;  but  milder  cases  of 
insomnia  will  be  benefited  by  exercise.  The  brain  should  be 
especially  allowed  to  rest  from  excitement  near  the  usual  hour 
for  sleep.  Hence  a  walk,  or  the  use  of  dumb-bells,  just  before 
bedtime,  will  be  suitable.  If  the  stomach  is  empty,  a  little 
easily  digested  food,  even  late  at  night,  will  promote  sleep,  not- 
withstanding the  familiar  fact  that  heavy  suppers  induce  wake- 
fulness or  nightmare.  A  glass  of  lager  beer  at  bedtime  is,  as 
my  own  experience  has  proved,  one  of  the  best  of  hypnotics. 

The  warm  bath  or  pediluvium,  with  cold  to  the  head,  will  some- 
times be  serviceable  in  abstracting  blood  from  the  brain.  Posi- 
tion of  the  body  is  important.  The  sufferer  from  insomnia  may 
often  be  very  sleepy  before  lying  down,  yet  after  going  to  bed  he 
becomes  wide  awake.  Several  jiersons  in  such  case,  to  my 
knowledge,  have  found  it  best  to  recline  with  the  head  and 
shoulders  raised.  Thus,  by  gravitation,  the  flow  of  blood  to  the 
head  is  retarded  and  sleep  is  promoted. 

As  medicines  for  simple  insomnia,  in  the  absence  of  pain,  opium 
and  other  powerful  narcotics  are  not  appropriate.  Hops,  lactuca- 
rium,  and  hyosoyamus  arc  safer.  Bromide  of  potassium,  in  10  or 
20  grain  doses,  is  much  used  as  a  cerebro-vascular  sedative  [F. 

1  Dr.  Herbert  Norris  treated  successfully,  in  the  Pennsylvania  Hospital  (1868),  four 
cases,  in  which  restlessness  was  a  prominent  symptom,  by  the  hypodermic  injection 
of  one-quarter  of  a  grain  of  sulphate  of  morphia.  Dr.  Marino,  of  Palermo,  asserts 
that  ergothi,  hypodermically  used,  is  very  efficacious  in  sunstroke. — Gazz.  Clin,  di 
Palermo,  June,  187G.  Tomlinson  and  Murphy  report  success  with  hydrochlorale  of 
aiiomoriihia ;  one-sixteenth  of  a  grain  producing  vomiting  and  relief. — PractUioner, 
June,  1880. 

32* 


378    DISEASES   OF   BRAIN   AND   NERVOUS  SYSTEM. 

134],  Its  action  appears  to  differ  from  tliat  of  morphia^  as  it  will 
not  produce  sleep  by  narcosis  in  a  healthy  person.  It  seems 
rather  to  relieve  insomnia  by  allaying  the  local  or  general  irrita- 
bility which  causes  or  maintains  it.  Dr.  Da  Costa  ^  has  found 
the  combination  of  bromide  of  potassium  (40  grains)  with  opium 
or  morphia  to  correct  the  unpleasant  effects  of  the  opiate,  while 
it  adds  to  its  hypnotic  power.  Hydrate  of  chloral  is  a  positive 
and  valuable  soporific.  In  15  or  20  grain  doses  it  seldom  fails, 
and  is  rarely  followed  by  any  disagreeable  after-effects. 

NIGHT-TEREORS. 

Dr.  C.  "West^  gives  the  following  description  of  an  attack  which 
is  not  very  uncommon,  occurring  in  infants  or  children  under  ten 
years  of  age.  "A  child  who  has  gone  to  bed  apparently  well,  and 
who  has  slept  soundly  for  a  short  time,  awakes  suddenly  in  great 
terror,  and  with  a  loud  and  piercing  cry.  The  child  will  be  found 
sitting  up  in  its  bed,  crying  out  as  if  in  an  agony  of  fear,  '  Oh, 
dear!  oh,  dear!  take  it  away!  father!  mother!'  while  terror  is 
depicted  on  its  countenance,  and  it  does  not  recognize  its  parents, 
who,  alarmed  by  its  shrieks,  have  come  into  its  room,  but  seems 
wholly  occupied  with  the  fearful  impression  that  has  aroused  it 
from  sleep.  Iii  from  ten  minutes  to  half  an  hour,  as  the  terror 
abates,  it  may  become  quiet  at  once  and  fall  asleep  ;  but  frequently 
it  bursts  into  a  fit  of  passionate  weeping,  and  sobs  itself  to  rest  in 
its  mother's  arms.  In  some  instances  a  quantity  of  limpid  urine 
is  voided  as  the  fit  passes  off,  but  this  occurrence  is  by  no  means 
constant.  Usually  the  remainder  of  the  night  is  passed  in  toler- 
ably sound  sleep ;  two  attacks  do  not  often  occur  in  the  same 
night."  "Seizures  of  this  kind  may  come  on  in  a  great  variety 
of  circumstances,  and,  according  to  the  cause  whence  they  have 
arisen,  may  continue  to  return  for  many  weeks  together,  or  may 
occur  but  a  few  times.  As  far  as  I  have  had  the  opportunity  of 
judging,  they  are  never  the  indications  of  primary  mischief  in  the 
brain,  but  are  alwa5^s  associated  with  some  disturbance  of  the 
intestinal  canal,  and  more  or  less  obvious  gastric  disorder.  In 
the  majority  of  cases  constipation  of  the  bowels  exists." 

My  experience  with  such  cases  confirms  that  of  Dr.  "West,  as 
indicating  that  these  attacks  do  not  prove  disease  of  the  brain. 
But  the  nervous  system  of  a  child  so  affected  must  be  morbidly 
susceptible  ;  and  signs  of  indigestion,  constipation,  or  irritation 
of  the  bowels  are  not  always  present. 

During  the  attack,  the  child  should  be  at  once  gently  lifted  up 
from  the  bed,  and  either  carried  for  a  few  moments  or  laid  down 
in  a  different  position.  Washing  the  face  softly  with  a  rag  dipped 
in  cool  or  cold  water  may  arouse  thoroughly.  If  any  medicine  be 
suitable,  it  will  be  a  teaspoonful  or  two  of  camphor-water.  Care 
is  needed  to  prevent  the  attacks.  Violent  exercise  and  mental  excite- 
vient  are  almost  as  apt  to  bring  them  on  as  indigestion  or  consti- 
pation. The  bowels  should,  however,  be  kept  open,  as  by  fluid 
extract   of  rhubarb,   or  senna,    etc.     Bromide  of  potassium   is 

1  Am.  Journal  of  Med.  Sciences,  April,  1871,  p.  359. 

2  Diseases  of  Children,  p.  210. 


TON  vur,sioNS.  379 

advised  by  Dr.  S.  Ringer  iii  obstinate  recurrent  attacks.  Some 
practitioners  prefer  cbloral,  in  from  tbree  to  six  grain  doses.  To 
promote  tranquil  sleep,  some  one  sbould  remain  witb  tbe  cbild, 
if  timid,  for  a  wbile  after  it  goes  to  bed  ;  or  a  ligbt  sbould  ])e  left 
burning  low.  A  cbild  liable  tonigbt-terrors  ougbt  to  be  allowed 
to  linisb  its  morning  sleep  undisturbed.  Abundance  of  sleep  is 
sedative  to  an  over-excitable  brain.  Neglect  of  such  precautions 
may  convert  a  mere  transitory  functional  disturbance  into  a 
serious  attack  of  brain  disease. 

CONVULSIONS. 

These  may  be  classified  as,  principally,  infantile,  epileptic, 
parturient  and  puerperal,  hysterical,  and  occasional  convul- 
sions. 

During  infancy,  causes  which  in  an  adult  would  cause  delir- 
ium produce  convulsions ;  excito-motor  action  having  in  early 
life  the  ])redominance,  and  being  then  less  under  the  control  of  the 
brain.  They  are,  usually,  of  less  serious  prognosis  in  the  infant 
than  in  the  adult. 

The  exciting  causes  of  infantile  convulsions  are  numerous. 
Constipation  of  the  bowels ;  indigestion ;  worms ;  irritation  of 
the  gums  in  teething ;  and  excitement  of  the  brain,  as  by  fright, 
are  the  most  frequent.  Many  acute  and  chronic  diseases  of 
infancy  (c.  r/.,  scarlet  fever,  meningitis,  hooping-cough,  etc.), 
have  convulsions  among  their  occasional  symptoms  or  complica- 
tions. Sudden  drying  up  of  eruptions  on  the  scalp  may  bring 
them  on,  also.  Bouchut  has  shown  that  cerebral  thrombosis 
(obstruction  of  the  veins  by  coagula)  is  often  the  pathogenetic 
cause  of  convulsions  in  the  chronic  diseases  of  childhood. 

Premonition  of  a  fit  may  be  observed  in  a  child's  fret  fulness, 
or  restlessness,  or  gritting  of  the  teeth  in  sleep.  When  a  fit 
comes  on,  the  muscles  of  the  face  twitch,  the  body  becomes  rigid 
at  first,  then  in  a  state  of  jerking  motion ;  the  head  and  neck  are 
drawn  backward,  the  limbs  violently  flexed  and  extended.  Some- 
times these  movements  are  confined  to  certain  muscles,  or  are 
limited  to  one  side.  Nurses  call  by  the  name  of  "  inward  fits  " 
cases  in  which  the  limbs  move  but  little,  but  the  countenance  is 
aflected,  tbe  eyes  are  unnatural  in  expression,  or  roll  spasmod- 
ically, and  the  body  is  more  or  less  rigid.  During  a  fit,  con- 
sciousness is  absent.  The  eye  shows  no  sign  of  sight,  though 
open ;  a  finger  passed  over  it  does  not  make  it  wink.  The  pupil 
is  immovably  contracted  or  dilated ;  the  ear  is  insensible  even  to 
loud  sounds.  The  pulse  is  small  and  very  frequent ;  breathing 
hurried  or  labored ;  skin  wet  with  perspiration,  often  cold  and 
clammy.  After  this  condition  has  lasted  a  few  minutes  it  mostly 
gives  way.  The  child  fixUs  into  a  quiet  sleep ;  or  it  becomes  con- 
scious and  bewildered  ;  or  gradually  resumes  its  ordinary  healthy 
state  ;  or  dies  in  the  fit.  Sometimes  one  attack  is  followed  by  an- 
other, with  intervals  of  conscious  or  unconscious  quiet  between, 
for  many  hours.  These  are  the  most  serious  cases,  although 
recovery  often  happens  even  from  them.  Salaam  convulsions, 
or  nodding  convulsions  of  infants  (eclampsia  nutans),  are  a  rare 
form  of  disease,  usually  the  precursor  of  epilepsy. 


380    DISEASES   OF  BRAIN  AND   NERVOUS  SYSTEM. 

Treatment.— Ascertain,  if  possible,  the  cause  of  the  convulsion. 
If  the  gums  are  swollen,  or  have  been  tender  and  irritated,  at  the 
time  of  teething,  lance  them  freely;  dividing  the  gum  with  a 
sharp  gum-lancet  down  to  the  coming  tooth. 

This'  practice,  formerly  universal,  has  been  objected  to  by 
Trousseau,  and  scarcely  sustained  by  Rilliet  and  Barthez. 
Marshall  Hall  strongly  urged  it,  in  accordance  with  the  theory 
of  reflex  irritation,  which  explains  the  convulsions  of  abnormal 
dentition.  Dr.  C.  "West  says  "'the  circumstances  in  which  the 
use  of  the  gum-lancet  is  really  indicated  are  comparatively  few. " 
If  this  be  true,  I  believe  that  they  are,  nevertheless,  very  impor- 
tant. Dr.  A.  Jacobi  (Dentition  and  its  Derangements,  p.  171) 
testifies  that  he  has  seen,  once  or  twice,  the  instant  cessation 
of  convulsions  upon  lancing  the  gums.  Dr.  J.  Finlayson^  has 
collected  reports  of  a  number  of  fatal  hemorrhages  following  the 
operation.  Others  assert  injury  to  the  growth  of  the  teeth,  cic- 
atrices, etc.  All  these  objections  do  not,  in  my  mind,  outweigh 
the  frequent  and  manifest  advantage  which  I  have  seen  in  prac- 
tice, from  clean,  free  incisions  (not  gouging  or  laceration)  of  the 
gums,  when  they  are  congested  or  inflamed,  or  when,  with  tension. 
without  congestion,  they  are  evidently  a  source  of  nervous  irritation 
to  the  child.  I  have  several  times  known  a  child,  after  the 
experience  of  relief  obtained,  asfc  for  the  use  of  the  lancet.  In 
a  very  extensive  practice,  lasting  for  half  a  century,  my  father, 
the  late  Dr.  Joseph  Hartshorne,  met  with  no  accident  from 
lancing  the  gums,  and  retained  his  confidence,  to  the  last,  in  its 
frequent  utility. 

If  the  bowels  have  not  been  moved,  or  if  the  abdomen  be 
swollen  and  tense,  give  at  once  an  enema,  of  castor  oil,  soap, 
and  molasses  [F.  141J,  or  some  other  laxative  material,  with 
warm  water.  When  the  head  is  hot,  apply  cold  water  all  over 
it,  by  wet  cloths,  renewed  every  two  or  three  minutes.  If  the 
fit  lasts  long  enough  for  it,  place  the  child  in  a  warm  bath  ;  sup- 
porting, of  course,  the  head  while  the  body  is  immersed.  Then 
mustard  plasters  may  be  applied,  to  the  back,  epigastrium,  and 
legs,  at  once,  or  successively.^ 

Bleeding  from  the  arm  is  to  be  recommended  only  in  a  child  of 
known  vigor  and  fulness  of  system,  the  attack  being  severe,  and 
not  habitual.  But  a  moderate  amount  of  blood  should  be  taken. 
Cupping  the  back  of  the  neck,  in  doubtful  cases,  where  time  is 
allowed  by  a  protracted  fit,  may  be  resorted  to.  Pressure  upon 
one  or  both  carotid  arteries  is  said,  by  M.  Favez,  to  have  promptly 
succeeded  in  checking  convulsions. 

Etherization,  so  much  used  by  some  practitioners  in  puerperal 
convulsions,  requires  certainly  more  caution  in  its  use  in  infants. 
I  regard  it  as  justifiable  in  an  obstinate  case  at  any  age  ;  watch- 
ing its  effects.  Dr.  J.  Lewis  Smith  uses  with  reported  advantage 
rectal  injections  of  hydrate  of  chloraU 

Convulsions  of  Pregnancy. — Probably   about    one  pregnant 

1  Obstet.  Journal  of  Great  Britain,  December,  1873,  and  January  and  February,  1874. 

2  The  objections  urged  by  Dr.  Hammond  and  some  others  to  this  usual  practice  do 
not  appear  to  me  to  be  well  founded. 

3  N.  Y.  Med.  Record,  May  8,  1880,  p.  522. 


CONVULSIONS.  381 

woman  in  fifty  has  more  or  less  albuminuria,'  principally  from 
the  pressure  of  the  womb  upon  the  renal  veins  producing  con- 
gestion of  the  kidneys.  Ai)out  one  in  ten  of  these  will  have 
epileptiform  convulsions,  either  during  gestation,  while  in  labor, 
or  after  delivery. 

Pathology.  —  All  convulsions  of  pregnant  women  are  not 
uraimic;  this  has  been  proved.  There  are  (putting  aside  in- 
stances of  Bright's  disease  already  existing)  several  conditions 
possible:  1.  Urremia ;  2.  Cerebro-spinal  reflex  irritation,  of 
uterine  origin;  3.  Cerebro-spinal  (apoplectic)  congestion,  con- 
nected especially  with  the  bearing-down  eftbrts  of  labor  itself; 
4.  According  to  Traube,  cerebral  tedema  and  consequent  ansemia. 

Treatment, — It  is  important,  particularly  during  gestation :  1. 
That  plethora  should  be  avoided ;  2.  That  free  action  of  the  kid- 
neys, as  well  as  regularity  of  the  bowels,  should  be  maintained. 
For  the  first,  care  of  the  diet  is  proper,  that,  in  women  of  full 
habit,  it  be  not  too  highly  animalized  or  stiiiiulant.  If  head- 
ache, with  a  full,  hard  pulse,  occur,  a  mild  cooling  laxative  may 
be  given ;  if  not  relieved,  cups  to  the  nucha  or  bleeding  from  the 
arm  will  be  a  safeguard.  When  urination  is  not  free  and  copious, 
even  if  no  albumen  appear  in  the  urine,  cream  of  tartar,  a  tea- 
spoonful  or  more  every  day  or  two,  or  acetate  of  potassium,  may 
be  a  useful  prophylactic,  by  favoring  free  excretion  from  the 
kidney. 

When  convulsions  actually  occur,  in  the  pregnant  or  puerperal 
state,  the  question  is  to  be  considered — are  they  reflex,  ursemic, 
or  simply  congestive  or  apoplectic? 

When  they  come  without  previous  signs  of  cerebral  disturbance, 
in  a  woman  of  delicate  and  impressible  nervous  organization, 
"without  much  heat  of  head  or  snoring  respiration,  the  pulse 
being  rapid  and  feeble,  it  is  probable  that  refleo:  irritation  is  the 
nature  of  the  case.  Counter-irritation  by  dry  cups  to  the  spine 
and  sinapisms  to  the  epigastrium  and  limbs,  and  etherization,  may 
be  here  used. 

Inhalation  of  nitrite  nf  amyl  (a  few  drops')  sometimes  relieves.^ 
Where  the  convulsions  are  repeated,  hydrate  of  chloral,  in  full 
dose,  has  been  given  (A.  Milne).  Conderau  has  found  advantage 
in  using  a  hypodermic  injection  of  three-fourths  of  a  grain  of 
muriate  of  morphia,  followed  in  a  few  minutes  by  a  large  dose  (a 
drachm  or  more  i  of  chloral  hydrate.  In  convulsions  beifore  labor, 
Fordyce  Barker  combines  the  hypodermic  use  of  morphia  with  the 
inhalation  of  chloroform.  Dr.  Fearu''  and  others  repoi't  excellent 
results  with  large  doses  (half  a  drachm  or  a  drachm  of  ISTorwood's 
tincture,  or  one-half  as  much  of  Squibb's  extract)  of  veratrinn 
viride.  This  remedy,  so  powerfully  depressing  under  ordinary 
circumstances,  can  surely  be  adapted  only  to  sthenic  cases ; 
especially  in  vigorous  women,  where  the  pulse  is  hard  or  firm  as 
well  as  rapid.     Some  unfavorable  results  under  its  employment 

1  A  different  reaction  with  oxide  of  copper  and  potassa  has  been  observed  in  the  albu- 
men of  Hriifht's  disease,  from  that  of  the  albuminuria  of  pregnancy. 

aVV.  F.  Jenks,  Philadelphia  Med.  Times,  Aug.,  1872. 

8N.  Y.  Medical  Kecord,  March  16,  1874.  Dr.  Fearn's  first  paper  on  the  subject  was 
published  in  1869. 


882    DISEASES    OF    BRAIN    AND    NERVOUS   SYSTEM, 

have  been  reported.  Still,  in  desperate  cases,  it  is  well  worthy 
of  further  trial.  Brauu  (1879)  treated  a  case  successfully  with 
hypodermic  injection  of  inlocarpin. 

When  plethora  has  been  present,  and  the  head  is  hot,  its  vessels 
distended,  the  coma  profound,  with  snoring  respiration,  and  full, 
rather  slow  pulse,  either  ursemia  or  simple  congestive  apoplexy  is 
to  be  concluded  upon.  In  either  case,  but  especially  in  the  latter, 
bleeding  from  the  arm,  or  by  cups  from  the  back  of  the  neck  or 
temples,  will  be  advisable.  Laxative  enemata  may  be  used  also. 
After  bleeding,  if  the  convulsions  be  protracted,  while  the  coma 
is  less  intense,  careful  inhalation  of  ether  or  chloroform  may  be 
tried  ;  but  it  is  less  hopeful  here.  The  prognosis  of  the  apoplecti- 
form convulsion  is  always  one  of  great  danger.  The  urcemic 
condition,  if  labor  be  survived,  generally  passes  off  spontaneously, 
soon  after  delivery. 

The  signs  commonly  interpreted  as  indicating  plethora  during 
pregnancy  are  by  some  (Cazeaux)  ascribed  to  hydrcemia,  with 
(Frank,  Munk)  increased  arterial  tension.  If  this  view  be  correct, 
as  it  may  be,  probably,  with  regard  to  some  cases,  we  may  still 
expect  moderate  venesection  to  be  a  useful  mode  of  treatment  ; 
only,  the  support  of  the  patient  ought  to  be  afterwards  provided 
for  by  strong,  concentrated  nourishment.^  Prof.  J.  Carson,  in 
an  elaborate  article^  on  puerperal  eclampsia,  asserted  the  belief 
that  the  tendency  to  convulsions  during  pregnancy  depends  upon 
"  altered  nutrition  of  the  nervous  centres." 

Upon  the  idea  of  "oedema  of  the  brain"  Jaquet,  of  Berlin, 
advises  the  wet  pach  (sheet  wrung  out  of  cold  water)  for  diapho- 
resis. 

Occasional  convulsions  in  adults,  from  whatever  cause,  should 
be  studied  and  treated  upon  the  same  principles,  essentially,  as 
those  just  Ifiid  down  for  the  convulsions  of  pregnancy.  Hysteri- 
cal convulsions  will  be  considered  under  Hysteria. 

CHOREA. 

S3niOiiym. — St.  Vitus''s  Dance. 

Symptoms. — Irregular  movements  of  the  voluntary  muscles, 
over  which  the  wiU  has  but  partial  control.  Walking,  in  severe 
cases,  is  difficult  or  unsafe ;  the  hands  cannot  be  regulated 
enough  to  write  or  work ;  speech  may  be  affected  ;  the  muscles 
of  the  face  often  twitch  grotesquely.  During  sleep  all  these 
movements  cease.  The  pupil  is,  in  some  cases,  unnaturally 
dilated  ;  palpitation  of  the  heart  may  occur  ;  and  also  constipa- 
tion and  indigestion.  The  urine  is  of  great  density.  A  cardiac 
murmur  is  often  heard  on  auscultation,  which  Sir  Wilham  Jenner 
affirms^  to  be  owing  to  irregular  action  of  the  muscular  appa- 
ratus of  the  mitral  valve  ;  sometimes  with  irregular  contraction 
of  the  heart  itself. 

Prognosis.— The  mean  duration  of  chorea  is  about  four  weeks  ; 
but  it  may  last  for  several  months.     Recovery,  if  the  attack  be 

1  See  Fordyce  Barker  on  Bloodletting  in  Obstetric  Medicine ;  D.  Appleton  &  Co.,  1871. 

2  Am.  Journal  of  Med.  Sciences,  April,  1871,  p.  405. 
SLancet,  Nov.  5,  1870. 


CHOREA.  •         383 

uncomplicated,  may  always  be  anticipated.  Dr.  J.  ^Y.  Oslo, 
however,  has  reported  the  details  of  sixteen  fatal  cases.^  The 
so-called  post-paralytic  chorea  (Weir  Mitchell),  hemichorca,  or 
heniikinesis  of  Hughlini^s-Jackson,  is  a  quite  dillerent  affection 
from  ordinary  chorea.  It  follows  hemiplegia,  in  rare  instances, 
and  is  often  incurable.  The  occurrence  of  any  form  of  paralysis, 
in  a  case  which  commences  as  chorea,  is  always  a  very  unfavor- 
able sign  ;  although  patients  thus  affected  may  often  live  for  a 
long  time. 

Complications. — Endocarditis  and  pericarditis  have  been  ob- 
served in  connection  with  chorea  in  a  number  of  cases.  Gen- 
erally, however,  the  affection  of  the  heart  precedes  the  chorea ; 
both  probabl}'  depending  upon  the  same  cause,  rheumatism.  Men- 
tal derangement  sometimes  accompanies  chorea.  Drs.  Kirkes, 
Hughlings-Jackson,  and  Broadbent  believe  the  disease  to  be  often 
dependent  upon  embolism  of  the  cerebral  arteries ;  especially 
those  of  the  corpus  striatum  and  thalamus. 

Paralysis  complicating  chorea  increases  greatly,  of  course,  the 
seriousness  of  the  case.  Although  it  may  be  of  the  transient, 
hysterical  form,  yet  the  danger  exists  that  it  may  be  the  result 
of  organic  lesion  of  the  brain  or  spinal  cord. 

Causation. — From  six  to  sixteen,  in  both  sexes,  especially  often 
in  girls,  chorea  occurs.  It  is  extremely  rare  in  negroes.  Nervous 
deljility  is  nearly  always  present  before  the  attack.  Fright  is  a 
frequent  cause.  Over-flitigue,  or  mental  excitement,  blows  or 
falls  may  produce  it.  Rheumatic  fever  is  sometimes  followed 
by  it. 

Treatment.— Good  diet,  salt-bathing,  and  systematic  gymnastic 
exercises  (light  gymnastics  or  calisthenics)  will  suffice  for  mild 
cases.  Where  marked  antemia  exists,  iron  (citrate,  phosphate 
[F.  142],  or  pyrophosphate,  tincture  of  chloride,  syrup  of  iodide) 
is  important.  Obstinate  cases  may  be  treated  with  Fowler's 
solution  of  arsenic,  in  small  doses,  gradually  increased.  Cimici- 
fuga  has  been  a  good  deal  used,  perhaps  with  benefit.  Cod-liver 
oil  should  be  given  if  great  debility  exists.  Gcdahar  hean  (physo- 
stigma)  has  been  introduced  as  a  remedy  in  chorea ;  f3ss  of  the 
tincture,  or  from  gr.  j  to  gr.  vj  of  the  powder  thrice  daily.  Dx*. 
C.  West  confides  in  the  sulphate  of  zinc.  Dr.  Hammond  has  used 
the  sulphate  of  'manganese  with  success.  Ether-spray  applied  to 
the  spine,  four  or  five  minutes  at  a  time,  every  day,  is  reported 
to  have  been  curative  in  the  hands  of  Dr.  John  Rose'-*  and  Per- 
roud  of  Lyons. ^  Bromide  of  potassium  has  been  tried,  without 
very  much  advantage.  Chloral  ought  to  be  of  service  in  this 
disease.  Trousseau  used  strychnia  ;  if  employed,  it  should  be 
with  great  caution.     Electricity  has  sometimes  done  good. 

It  is  well  to  separate  a  child  having  severe  chorea  from  other 
children ;  both  because  of  the  annoyance  of  their  curiosity,  and 
because  sympathetic  irritation  sometimes  extends  the  affection 
from  one  to  another.     This  has  been  repeatedly  observed. 

1  Brit,  and  Foreign  Medico-Chirurg.  Review,  January,  1868. 

-  Lancet,  Dec.  10, 1870.  ■>  l^hil.  Med.  News,  February,  1870. 


384    DI-SEASES    OF    BRAIN   AND   NEIiVOUS   SYSTEM. 

APHASIA. 

Loss  of  speech  may  occur  as  one  of  the  symptoms  of  disease 
of  the  brain,  either  functional  and  transient,  or  organic  and 
irremovable.  Such  a  loss  of  language  is  termed  (Bouiilaud) 
aphasia.  Importance  has  been  given  to  it  by  the  observations  of 
Trousseau  and  others,  and  resulting  speculations  (Dax.  P.  Broca) 
as  to  the  seat  of  the  faculty  of  speech.  Kot  articulation,  as  in 
aphonia,  but  expression  is,  in  this  affection,  wanting.  The  power 
to  write  words  from  memory,  to  convey  meaning,  is  lost ;  but,  in 
some  cases,  at  least,  they  may  be  copied  correctly.  ThinMng 
without  ivords  may  go  on  in  such  instances ;  as  Lordat  recorded, 
after  recovery,  in  his  own  case.  In  certain  cases,  especially  in 
hysterical  persons,  the  loss  of  speech  appears  to  be  "spasmodic" 
or  functional,  without  permanent  disease  of  the  brain. 

Hemiplegia  of  the  right  side  has  in  a  number  of  examples  coin- 
cided with  aphasia  ;  and,  several  times,  also,  autopsy  has  shown 
softening  or  other  lesion  of  the  left  anterior  portion  of  the  cere- 
brum. On  the  suggestion  of  these  facts  a  hypothesis  has  been 
based,  that  the  site  of  the  faculty  of  language  is  in  the  third 
anterior  frontal  convolution  of  tlie  left  hemisphere  of  the  cere- 
brum. This  is  a  very  unphysiological  supposition,  in  view  of  the 
symmetry  of  the  cerebro-spinal  axis  throughout ;  nor  does  this 
objection  disappear  even  upon  the  conjecture  that  the  "organ" 
upon  the  right  side  may  exist  always  in  an  undeveloped  state. 
A  remarkable  case  has  been  reported,^  in  which  impairment  of 
speech  followed  a  severe  injury  of  the  right  cerebral  hemisphere. 
A  number  of  instances  of  a  similar  kind,  adverse  to  Broca's 
theory,  have  been  collected  by  Dr.  J.  W.  Ogle.^  Valvular  lesion 
of  the  heart  sometimes  accompanies  aphasia.  Embolism  is  pos- 
sibly an  occasional  cause  of  it.  Dr.  H.  C.  Bastian^  divides  the 
cases  into  aphasia,  when  the  patient  can  think,  but  cannot  speak 
or  write ;  aphemia,  when  he  can  tliink  and  write,  but  not  speak  ; 
and  agraphia.,  when  he  can  think  and  speak,  but  not  write. 

Cases  of  aphasia  are  rare.  I  am  not  aware  of  any  special 
measures  of  treatment  for  it  pointed  out  as  yet  by  experience. 
Dr.  Osborne  recommends  (having  succeeded  with  it  in  one  case) 
teaching  the  patient  to  speak  anew,  as  is  done  in  infancy. 
While  this  can  have  no  effect  upon  the  cerebral  lesion,  it  may 
much  diminish,  in  some  cases,  at  least,  the  inconvenience  of 
the  resulting  symptoms. 

TETANUS. 

Definition.— A  disease  characterized  by  continued  and  intract- 
able tonic  contraction  of  the  voluntary  muscles.  Trismus  is 
local  tetanus  or  lock-jaw. 

Symptoms. — Stiffness  of  the  muscles  of  the  jaws  commonly 


1  Western  Journal  of  Medicine,  March,  1868. 

2  London  Lancet,  March  21,  1868.  See  also  Dr.  Wadham's  case,  St.  George's  Hospital 
Reports,  1869 ;  and  one  reported  by  Dr.  Echeverria  (N.  Y.  Medical  Record,  March,  1869), 
in  which  post-mortem  examination  revealed  sclerosis  of  both  third  anterior  frontal 
convolutions,  without  symptoms  of  aphasia  having  occurred. 

3  Brit,  and  Foreign  Medico-Chinirg.  Rev.,  January  and  April,  1869. 


TETANUS.  385 

begins  the  attack.  This  extends  to  the  throat  and  neck,  face^ 
trunk,  and  lastly  to  the  limbs.  Thouixh  never  ceasing  entirely, 
the  spasm  of  the  muscle  is  paroxysmally  increased.  Sometimes 
opwUiotonos  occui's,  i.  c,  arching  of  the  body  upon  the  back  and 
heels,  the  abdomen  projecting ;  or  emprosUiotonos^  arching  for- 
ward, the  face  approaching  towards  the  toes.  Pleitrosthotonos, 
or  lateral  curvature,  is  much  more  uncommon. 

Chewing  food  is  impossible;  swallowing  nearly  or  quite  so; 
respiration  becomes  very  diflicult.  The  patient  suffers  dread- 
fully, and  cannot  sleep;  but  delirium  scarcely  ever  occurs. 
Death  in  most  cases  takes  place  within  a  week. 

Varieties. — These  are,  1.  tetanus  from  cold  (idiopathic),  2. 
traumatic  tetanus  (from  an  injury),  and  3.  trismus  iiascentmni^  or 
tetanus  of  infancy.     The  first  is  least  certain  to  be  fatal. 

The  third,  tetanus  oieonatorum,  is  rare  in  Philadelphia,  some- 
what less  so  in  the  tenement  houses  of  New  York  ;  common  in 
Iceland,  the  Hebrides,  and  some  tropical  countries.  It  was 
formerly  not  very  uncommon  among  the  negroes  of  the  planta- 
tions of  the  Southern  States.  Its  chief  cause  is  dose,  unsanitary 
living.  Some  foundling  hospitals  have  suffered  great  mortality 
from  it.  The  time  for  its  occurrence  is  mostly  within  the  first 
two  weeks  after  birth  ;  and  death  usually  occurs  within  two  or 
three  days.  In  symjjtoms,  this  form  of  tetanus  differs  from  that 
of  adults  chiefly  in  the  frequent  occurrence  of  clonic  spasms  of 
the  voluntary  muscles,  or  of  paroxysms  of  extreme  rigidity. 
These  are  produced  by  slight  causes  ;  as  a  sudden  sound,  a  fiash 
of  light,  a  breath  of  air.  Recovery  from  the  attack  is  scarcely 
to  be  looked  for  in  any  case.  Yet  recoveries  have  been  reported  ; 
by  Drs.  Gaillard  and  De  Saussure,  under  treatment  with  can- 
nabis indica;  by  Dr.  G.  Troup  Maxwell  and  others,  with  chloral. 
Dr.  Osterlong,  of  Kentucky,  has  succeeded  with  injections  of 
chloral  into  the  rectum. 

CoUes,  of  Dublin  (181S),  called  attention  to  evidence  making 
it  appear  that  inflammation  of  the  umhilicus  connected  with  the 
cord  is  a  frequent  local  source  of  tetanic  irritation  at  the  time 
of  birth.  Sims  (184G)  published  cases  seeming  to  show  that 
pressure  of  tJie  occipjital  bone  upon  the  medulla  oblonc/ata  at  the 
time  of  delivery  produces  trismus  nascentium  ;  and  that  laying 
the  child  upon  its  side  at  once  after  birth  may  prevent  the 
attack.  But  many  cases  of  the  disease  have  occurred  in  which 
neither  Colles'  nor  Sims'  mode  of  causation  could  be  ascer- 
tained. While,  therefore,  each  may  have  a  considerable  share 
in  its  production,  neitlier  can  be  regarded  as  universal  or 
essential. 

Much  the  greater  number  of  cases,  after  infancy,  results  from 
lacerated  and  punctured  wounds ;  but  amputations  and  other 
operations  may  be  followed  by  tetanus.  Irritation  (not  inflam- 
mation) of  tlie  ends  of  sensitive  nerves,  transmitted  to  the  spinal 
cord,  produces  the  reflex  spasm,  whose  general  extension  and 
continuance  prove  fatal.  Strychnia,  in  poisonous  doses,  causes 
a  very  similar  state.  While  there  can  be  no  doubt  that  the 
spinal  marrow  is  the  seat  of  tlie  disease,  no  characteristic  organic 
change  has  been  found  in  it ;  sometimes  not  even  congestion. 
33  Z 


386    DISEASES   OF  BEAIN   AND   NERVOUS   SYSTEM. 

Dr.  Allbutt  has  recently^  reported  softening  of  the  cord  in  four 
traumatic  cases. 

Causation.— This  is  principally  included  in  the  above  ac- 
count. 

Treatment.— In  two  cases  of  tetanus  which  I  have  seen  to  re- 
cover, opium  and  brandy  were  the  remedies  used.  A  tablespoon- 
ful  of  brandy  or  whisky  (to  an  adult)  every  two  or  three  hours, 
with  milk  or  beef-tea,  and  a  grain  of  opium  every  three  or  four 
hours,  may  be  given.  The  opium  may  be,  if  needful,  increased 
to  a  grain  every  hour  at  night,  and  every  two  hours  through  the 
day.  Beyond  that  I  would  not  go.  Hypodermic  injections  of 
morphia  will  answer  the  same  purpose. 

Chloroform  and  other  ansesthetics,  by  inhalation,  have  been 
tried,  with  variable  effect ;  nearly  always  without  success.  Bel- 
ladonna, conia,  aconite,  hydrocyanic  acid,  cannabis  indica, 
tobacco,  woorara,  and  quinine,  are  among  the  many  medicines 
favored  by  different  practitioners.  Demme  is  said  to  have  cured 
eight  cases  out  of  twenty-two  with  curara.  Drs.  E.  Watson,  of 
Glasgow,  and  Frazer,  of  Edinburgh,  have  used  Calabar  bean, 
one  grain  at  a  dose;  or  five  drops  of  the  tincture.^  In  so  des- 
perate a  disease  it  is  excusable  to  give  them  all  further  trial. 
Dr.  Joseph  Hartshorne  used  vigorous  counter-irritation  all  along 
the  spine,  by  the  decoction  of  cantharides  in  turpentine  (lini- 
mentum  cantharidis).  Lately  chloroform  has  been  locally  used  in 
the  same  way.  Hammond  advises  the  use  of  ice-bags  to  the  back ; 
Sporer,  a  succession  of  hot-water  compresses  along  the  back.  Per- 
roud,  of  Lyons,  has  employed  successfully  the  application  of  ether- 
sxjray  to  the  spine ;  Demarquay,  the  hot-air  hath.  CJiloral  has  been 
emi^loyed,  with  recovery  in  some,  though  not  in  all  cases,  by  Ver- 
neuil,  Dufour,  Denton,  Lavo,  Beck,  Coryllos,  Lewis, ^  and  others. 
It  has  proved  to  be  esiiecially  beneiflcial  in  trismus  nascentium. 

Prof.  E.  de  Eenzi*  draws  the  following  conclusions  from  his 
observations  of  tetanus : 

1.  Light  renders  the  tetanic  contractions  of  animals  and  man 
more  frequent  and  intense. 

2.  It  can  be  demonstrated  experimentally  in  animals,  that 
ahsolute  repose  during  the  absence  of  all  stimulus,  retards  the  teta- 
nus and  renders  it  less  fatal. 

3.  Of  three  cases  of  severe  tetanus,  treated  almost  exclusively 
by  absolute  repose,  two  cases  were  cured.  The  patients  were 
kept  isolated  in  a  dark  room ;  all  noise  or  other  stimulus  or  irri- 
tation was  avoided,  except  such  as  was  caused  by  the  adminis- 
tration of  food  and  beverage  at  long  intervals. 

When,  after  severe  local  injury,  the  nerves  of  the  part  appear 
to  be  involved  and  tetanic  symptoms  occur.  Key  and  Bryant 
approve  of  amputation.  In  1845,  Key  performed  this  operation 
successfully  on  account  of  tetanus  following  unreduced  disloca- 

1  Med.  Times  and  Gazette,  Feb.  18,  1871. 

2  Dr.  W.  W.  Keen  (Phila.  Med.  Times,  March  1,  1871)  gave  the  tincture  of  Calabar 
bean  (physostigma  venenosum)  in  doses  of  orae  or  two  hundred  minims,  in  a  case  in  which 
recovery  "occurred.  Of  18  cases  (collected  by  Dr.  E.  Watson)  in  which  physostigma  was 
used,  10  recovered. — Practilioner,  September,  1869. 

8  Am.  Journal  Med.  Sciences,  October,  1877,  p.  420. 
4  Gaz.  Med.  Ital.  Lombard.,  January,  1875. 


H  YD  It  OP  HOB  I  A.  387 

tion  of  the  astracfilns,  Sovoral  other  cases  seem  to  justify  the 
practice  in  anal()<ious  instances. 

Vogt,  of  (Jn'ifswakl,  reported'  the  cure  of  a  case  of  traumatic 
tetanus  in*  division  and  stretcliing  of  the  median  and  radial 
nerves  ;  tlie  disease  liaving  its  origin  in  a  severe  wound  of  the 
hand,  llelaxalion  of  muscular  rigidity  followed  the  operation 
almost  immediately.  Other  cases'-  have  occurred,  in  which 
division  of  nerves  connected  with  the  seat  of  peripheral  irrita- 
tion has  l)een  followed  by  recovery. 

Tetanus  has  been  treated  successfully  in  India  (Khastagir)  by 
inlialation  of  cannabis  Indica.  A  hookah  (native  pipe)  is  charged 
with  leaves  of  hemp,  alone  or  mixed  with  tobacco,  and  is  given 
to  the  patient  whenever  spasms  of  rigidity  begin.  Pie  soon 
becomes  drowsy,  perhaps  falls  asleep ;  when  the  pipe  is  with- 
di'awn.  Being  refilled  by  an  attendant,  it  is  used  again  and 
again  as  required,  keeping  him  constantly  under  its  influence.^ 

Corry,  of  Dublin,*  and  C.  Johnston,  of  Baltimore,  have  had 
cures  of  tetanus  under  the  use  of  conia.  Of  six  cases  of  trau- 
matic tetanus  treated  with  it  l)y  Dr.  Johnston, °  three  recovered. 

Dr.  "W.  S.  Forbes,"  of  Philadelphia,  cured  a  case  of  tetanus  in 
1875  by  inhalation  of  nitrite  of  amyl.  Tunkel,  of  Berlin,  and 
others,'  have  reported  similar  results. 

HYDROPHOBIA. 

I  have  known  a  physician  of  distinction  and  of  many  years' 
practice  to  deny  the  existence  of  hydrophobia  because  he  had 
not  seen  it ;  asserting  that  the  cases  so  called  were  tetanus. 
Having  seen  two  cases  of  it,  I  feel  sure  that  no  one  who  has 
observed  it  can  fail  to  perceive  the  wide  distinction  between  it 
and  tetanus. 

According  to  the  Eegistrar-General's  report,  there  were  in 
England,  in  1874,  sixty-one  deaths  from  hydrophobia ;  in  1875, 
forty-seven. 

Symptoms. — A  month  or  more  after  the  bite  of  a  mad  dog  or 
other  rabid  animal,  the  wound  having  healed,  irritation  is  felt  in  it. 
Nervous  restlessness  also  exists;  Avhich  increases, fin  most  though 
not  in  all  cases)  to  violent,  angry  delirium.  Then  difficulty  of  swal- 
lowing occurs,  from  spasms  of  the  muscles  of  inspiration  (gasping) 
taking  place  at  the  moment  of  deglutition,  making  the  patient 
choke.  The  same  spasmodic  gasping  is  brought  on  by  any  sud- 
den impression ;  as  of  sound,  a  flash  of  light,  or  even  a  current 
of  air  passing  over  the  face.  Insomnia  exists ;  the  patient  grows 
prostrate,  and  must  die  for  want  of  food  and  drink,  even  if  the 
aflection  of  the  cerebro-spinal  axis  were  not  itself  fatal.  There 
is  intense  thirst,  and  no  dread  of  water,  except  that  the  attempt 
to  swallow  it  causes  intolerable  distress.  Death  occurs  in  from 
four  to  eight  or  ten  days. 

I  have  not  met  with  entirely  satisfactory  evidence  that  a  case  of 
genuine  rabies  canina,  or  hydrophobia,  has  ever  been  cured.     By 

1  Centralblatt  fiir  die  Chirursiie,  No.  40,  1876.  -  Brain,  January,  1880. 

3  ]\Icd.  Times  aud  Gazette,  Feb.  21,  1880. 

*  Dublin  Quarterly  Journal  of  Med.,  November,  18G0. 

6  Am.  Journal  of  Med.  Sciences,  July,  1870. 

0  Philu.  Med.  Times,  June  12,  1875,  p.  590. 


388    DISEASES   OF  BRAIN   AND  NERVOUS  SYSTEM. 

statistics,  however,  only  one  in  eleven  (some  say  one  in  five') 
of  those  bitten  by  mad  dogs  have  the  disease,  even  when  no  pre- 
caution is  taken. 

Morbid  Anatomy.— Dr.  C.  Allbutt^  has  recorded  the  post- 
mortem appearances  in  two  cases.  There  were  evidences  of  vas- 
cular congestion,  serous  infiltration,  and  granular  degeneration 
in  the  great  nervous  centres :  worst,  in  the  medulla  oblongata ; 
next,  in  the  spinal  cord ;  thirdly,  in  the  cerebral  convolutions ; 
lastly,  in  the  central  cephalic  ganglia.  The  poison  causing  the 
disease  appears  to  act  primarily  upon  the  cerebro-spinal  system. 
Dr.  Hammond  made  a  similar  observation  in  a  fatal  case  in  'New 
York,  in  1874.  BruckmuUer,  of  Vienna,  discovered  oedema  of  the 
brain  in  a  number  of  cases ;  cerebral  hypersemia  in  all. 

In  dogs,  Eudnew,  of  St.  Petersburg,  found  the  kidneys  always 
severely  aflfected ;  affording  the  conditions  favoring  urcemia. 

Treatment. — If  we  cannot  cure,  what  can  or  should  we  do? 
We  may  certainly  promote  at  least  euthanasia,  by  allaying  the 
wretched  sufferings  of  the  patient.  In  the  case  of  a  boy  of  eight 
years  of  age,  under  my  own  care,  I  administered  chloroform  freely 
by  inhalation,  continuing  it  nearly  all  the  time  (with  short  inter- 
vals and  equally  short  applications)  for  two  days  and  nights.  It 
mitigated  the  spasms  and  quieted  the  delirium.  That  it  did  not 
itself  cause  death  (as  might  have  been  suspected  from  the  quan- 
tity used)  was  proved  to  my  satisfaction  by  the  fact  that  after  the 
chloroform  was  finally  withdrawn,  the  boy  was  made  to  gasp 
spasmodically  by  waving  the  hand  to  and  fro  over  his  face. 
Keflex  excitability  of  the  medulla  oblongata  was  thus  shown 
still  to  exist. 

Hypodermic  injection  of  atropia  or  morphia  might,  perhaps, 
more  efiectually  quiet  the  suffering,  and  even  afford  a  possibility 
of  cure,  than  inhalation  of  anaesthetics.  The  hot-air  bath,  pro- 
longed or  repeated,  has  lately  been  proposed  for  the  treatment  of 
hydrophobia.  Haschisch  (cannabis  indica)  is  asserted  by  PoUi, 
of  Milan,  to  be  its  best  palliative,  although  not  curative.  Curara 
is  reported  to  have  cured  at  least  one  case.^  The  unique  char- 
acter of  this  result  compels  me  to  doubt  the  correctness  of  the 
diagnosis.  One  or  two  other  recoveries,  under  the  same  treat- 
ment, are  spoken  of  by  authors,  but  I  have  not  been  satisfied  of 
their  authentication.  In  the  Lonibardy  Medical  Gazette,  June, 
1878,  a  case  is  said  to  have  recovered  under  the  care  of  two  Kus- 
sian  physicians,  the  treatment  being  the  inhalation  of  oxygen. 

Prophylaxis. — The  only  perfect  safety  to  one  who  is  bitten  by 
a  rabid  animal  (and  the  bite  of  a  much  enraged^  dog,  not  rabid, 
is  said  to  have  also  caused  hydrophobia)  is  in  immediate  and  total 
excision  of  the  part.     While  awaiting  this,  forcible  suction  will 

1  Bouley  (Arch.  Generales  de  Med.,  June,  1870)  found  that  of  320  persons  bitten,  129, 
or  40.31  per  cent.,  had  fatal  hydrophobia. 

2  Trans,  of  Pathological  Society,  1872. 

3  Oflfenberg,  1874.  See,  for  translation  of  full  report  of  this  case,  N.  Y.  Med.  Record, 
Aug.  9, 1879,  p.  124.  See  also  B.  A.  Watson,  case  treated  with  strychnia  and  woorara, 
Amer.  Journal  of  Med.  Sciences,  July,  1876,  p.  80.  Broadbent,  of  St.  Mary's  Hospital, 
London,  is  reported  to  have  cured  acase  of  rabies  in  a  boy,  in  1876,  by  injections  of 
hydrate  of  chloral.  In  all  these  cases  the  possibility  of  error  in  diagnosis  must  be  re- 
membered. 

<  Fleming,  an  authority  upon  hydrophobia,  denies  that  this  ever  occurs. 


HYDROPHOBIA.  389 

aid  in  I'cmoving  the  poison,  and  ligation  with  any  kind  of  bandage 
above  the  part  will  retard  the  alisorption  of  it.  When  excisi(jn 
cannot  be  safely  performed  t)r  is  refused,  cauterization  is  the  next 
best  thing.  Free  application  of  lunar  caustic,  or  of  a  red-hot 
wire,  or  the  explosion  on  the  part  of  a  small  quantity  of  gun- 
powder, is  reconnnended.  Even  if  the  person  bitten  is  not  seen 
until  a  day  or  two  afterwards,  excision  or  the  use  of  the  caustic 
is  to  be  recommended,  as  lessening  the  danger  of  this  horrible 
disease.  Marochetti  and  others  have  asserted  the  presence,  dur- 
ing the  incubation,  of  vesicles  or  pustules  near  the  frsenum  of  the 
tongue  (Zy/s.si),  the  cauterization  of  which  will  prevent  the  disease. 
This  requires  confirmation,  however.  The  saliva  of  a  human 
subject  of  hydrophobia  (as  well  as  that  of  rabid  animals)  has  been 
shown  by  experiments  upon  animals  (Kaynaud,  1879)  to  be  virulent. 

In  regard  to  the  detection  of  rabies  in  animals,  the  following 
hicid  instructions  have  been  issued  by  the  Council  of  Hygiene  of 
Bordeaux : — 

"A  short  time,  sometimes  two  days,  after  madness  has  seized 
a  dog,  it  creates  symptoms  in  the  animal  which  it  is  indispensable 
to  recognize : 

"  1.  There  is  agitation  and  restlessness,  and  the  dog  turns  him- 
self continually  in  his  kennel.  If  he  be  at  liberty,  he  goes  and 
comes,  and  seems  to  be  seeking  something ;  then  he  remains  mo- 
tionless, as  if  waiting ;  then  starts,  bites  the  air,  as  if  he  would 
catch  a  fly,  and  dashes  himself  howling  and  barking  against  the 
wall.  The  voice  of  his  master  dissipates  these  hallucinations ; 
the  dog  obeys,  but  slowly,  with  hesitation,  as  if  with  regret. 

"2.  He  does  not  try  to  bite;  he  is  gentle,  even  affectionate,  and 
he  eats  and  drinks,  but  gnaws  his  litter,  the  ends  of  curtains,  the 
padding  of  cushions,  the  coverlets  of  the  beds,  carpets,  etc. 

"3.  By  the  movement  of  his  paws  about  the  sides  of  his  open 
mouth,  one  might  think  he  was  trying  to  free  his  throat  of  a  bone. 

"  Jr.  His  voice  undergoes  such  a  change  that  it  is  impossible  not 
to  be  struck  by  it. 

"  5.  The  dog  begins  to  fight  with  other  dogs;  this  is  a  decidedly 
charactei'istic  sign,  if  the  dog  be  generally  peaceful. 

"The  three  symptoms  last  mentioned  indicate  an  advanced 
period  of  the  disease,  and  that  the  dog  may  become  dangerous 
at  any  moment  if  immediate  measures  are  not  taken.  It  is  best 
to  chain  him  up  at  once,  or  better  still,  to  kill  him." 

If  not  killed,  a  rabid  dog  will  die  of  the  disease  in  from  five  to 
eight  days. 

H.  C.  Hovey  (Am,  Journal  of  Sciences  and  Arts,  May,  1874) 
states  that  the  bite  of  the  American  skunk  produces  a  form  of 
rabies  {rabies  mephitica)  as  fatal  as  hydrophobia. 

Burrel's  proposal  to  prevent  danger  from  canine  rabies, by  filing 
or  nipi)ing  the  edges  of  the  incisor  and  canine  teeth  of  all  dogs 
left  at  lai-ge,  does  not  seem  likely  to  be  extensively  carried  out. 

It  is  a  mistake  to  supijose  that  madness  is  more  common  in  dogs 
during  hot  weather  (the  "dog  days  ").  Statistics^  show  that  at 
least  as  many  cases  occur  in  winter  as  in  summer. . 

1  Transactions  of  Am.  Medical  Association. 
33* 


390     DISEASES  OF   BRAIN   AND  NERVOUS  SYSTEM. 

HYSTERIA. 

From  its  occurring  nearly  always  in  females,  and  from  a  suppo- 
sition of  its  originating  in  some  affection  of  the  womb,  this  name 
has  been  given  to  a  variable  disorder,  of  which  the  main  charac- 
teristic is  morbid  excitability  of  the  whole  nervous  system.  Dr.  Todd 
believes  it  always  to  depend  on  disorders  of  the  blood.  Dr.  Tilt 
insists^  that  uterine  disorders  are  its  most  frequent  exciting 
causes. 

I  would  suggest  neurataxia  as  a  term  synonymous  with  hys- 
teria, and  more  descriptive  of  its  true  pathology.  Neurasthenia 
may  generally  be  at  the  bottom  of  it,  but  not  universally ;  and 
that  is  not  the  whole  of  it,  in  any  case.  I  mean  by  neurataxia, 
a  loss  of  balance  in  the  functional  action  of  the  nervous  centres,  both 
of  animal  and  of  organic  life.  Sometimes  the  symptoms  affect  the 
muscular,  sensorial  and  psychical  apparatus,  and  sometimes  the 
organs  of  digestion,  circulation,  respiration,  reproduction,  etc. 

A  "  fit  of  hysterics"  is  a  paroxysm  whose  nature  may  vary, 
from  mere  uncontrollable  laughter  or  crying  to  a  severe  epilepti- 
form convulsion.  This  last,  however,  differs  from  epilepsy,  in 
there  being  less  complete  loss  of  consciousness,  and  in  the  cura- 
bility of  the  disorder.  It  is  often  preceded  b}'  a  sensation  (globus 
hystericus)  like  that  of  a  ball  rising  toward  the  throat.  Charcot's 
assertion,  that  hysterical  convulsions  are  always  announced  by 
definite  premonitory  symptoms,  I  can  controvert  from  actual 
observation.  The  same  author  refers  to  the  decided  rise  of  tem- 
perature in  epileptic  attacks  as  usually  distinctive ;  and  states 
that,  in  hysterical  convulsions,  compression  over  the  region  of  the 
ovaries  will  arrest  or  modify  the  attack. 

Simulation  of  other  diseases,  indeed  the  assumption  of  severe 
functional  disorders  of  different  organs,  is  a  common  trait  of 
hysteria.  I  have  seen  complete  hysterical  amaurosis ;  hysterical 
insanity  is  not  uncommon,  nor  is  hysterical  paraplegia  or  coma 
rare.  Retention  of  urine,  cough,  aphonia,  etc.,  are  often  thus 
produced.  "  Phantom  tumor  "  is  among  the  most  curious  of  such 
things.  I  had  under  my  care  a  woman  who  had  been  laid  out  by 
a  surgeon  in  another  city  for  exploratory  gastrotomy,  under  the 
supposition  that  she  had  ovarian  tumor.  When  she  was  etherized, 
however,  the  tumor  altogether  disappeared!  '■'■Bed  case''''  is  the 
name  given  (Laycock)  to  the  complaint  of  an  hysterical  valetudi- 
narian, who  believes  herself  to  be  ill  or  powerless,  while  there  is 
really  nothing  the  matter,  except  the  morbid  neurosis  itself. 

Hysterical  hemianoesthesia  has  attracted  much  attention  latterly 
(1878-80),  especially  in  the  clinics  of  Charcot  at  the  Salpetriere, 
near  Paris.  One-half  of  the  whole  body,  in  these  cases,  is  almost 
or  quite  without  tactile  sensibility.  Sometimes  the  sense  of  pain, 
or  that  of  temperature,  may  be  alone  abolished.  Charcot  points 
out  the  usual  attendance  upon  this  condition  of  ovarian  hyperoes- 
thesia  upon  the  opposite  side. 

Burq,  in  1876,  announced  that  this  disorder  is  capable  of  mod- 
ification or  relief  by  the  external  application  and  internal  use  of 
certain  metals,  as  well  as  by  solenoids  (galvano-electric  spirals) 

1  London  Lancet,  Aug.  12, 1871. 


HYSTERO-EPILEPSY.  391 

and  ma2;nets.  Charcot,  Regnard,  Magiian,  Westphal  and  others 
have  confirmed  these  results.'  Of  course  there  is  a,  jjresumption^ 
to  be  removed  only  by  careful  and  prolonged  observation,  that 
mental  intlucnces  have  much  to  do  with  the  explanation  of  such 
phenomena. 

Treatment.— Much  skill  and  care  will  often  be  required  in  the 
management  of  hysteria,  as  each  case  has  peculiarities  of  its  own. 
Generally  a  tonic  regimen  is  demanded.  Dr.  Blandford  is  no 
doubt  right  in  estimating  very  highly  the  importance  of  (jood 
feeding  in  hysterical  and  other  forms  of  nervous  debility.'-'  Dr. 
S.  AVeir  Mitchell  advises,  in  some  cases,  rest,  massage,  and 
"excessive"  feeding.-*  Iron  and  cod-liver  oil  are  most  often  the 
appropriate  medicines.  Bromide  of  potassium  is  sometimes  quite 
useful.  For  a  paroxysm  of  "hysterics"  assafoetida  [F.  143]  is 
universally  safe  and  suitable,  in  pills  of  3  grains  each,  |jro  re  nata. 
Sinapisms  and  pediluvia  are  also  proper.  Guillemin  recommends 
inhalation  of  the  ethereal  tincture  of  valerian.  The  preparations 
of  valerian,  taken  internally,  may  be  useful ;  the  fluid  extract, 
tincture,  or  valerianate  of  ammonium  ;  and  so  also  may  be 
chloral.  Mono-bromated  camphor  has  been  given  with  asserted 
advantage,  by  Hammond^  and  others  ;  two  to  five  grain  doses,  in 
pill.  A  limited  trial  with  it  has  disappointed  me.  Menstruation 
is  often  irregular  in  hysterical  women ;  it  should  be  regulated  as 
far  as  possible.  Exercise  in  the  open  air  is,  as  a  rule,  very 
important  for  such  persons.  Mental  and  emotional  excitement 
should  be  avoided ;  but  tranquil,  even  engrossing  occupation  will 
be  beneficial.  For  hysterical  pai'alysis,  electricity  is  said  to  be 
generally  useful.  De  Watteville^  and  Yigoureux'^  recommend 
statical  (friction)  electricity  in  hysteria  generally.  Cold  bathing, 
especially  the  shower-bath  or  sea-bathing,  when  followed  by 
reaction,  will  do  good.  Feeble  and  delicate  persons  should,  how- 
ever, be  careful  not  to  remain  in  the  bath  too  long.  In  the  surf, 
for  example,  a  bath  of  five,  ten,  or  fifteen  minutes  may  be  of 
great  service,  when  a  longer  time  would  do  real  harm. 

HYSTERO-EPILEPSY. 

Under  this  name  are  described  a  number  of  remarkable  cases, 
especially  reported  upon  by  Charcot,  Briquet,  and  Bourne ville,  in 
which  the  characters  of  hysteria  and  epilepsy  appear  to  be  com- 
bined. A  few  cases'  only  have  been  studied  outside  of  Salpe- 
triere.  The  typical  history  of  the  disorder  is  connected  with  some 
famous  examples  in  that  institution.  Retrospectively,  however, 
resemblance  may  be  believed  to  exist  between  them  and  the  epi- 
dermic nervous  disturbances  of  the  IGth,  17th,  and  18th  centuries; 
particularly  the  "  convulsionnaires  de  St.  Medard." 

The  subjects  of  hystero-epilepsy  are  all  women.     Most  of  them 

1  See  an  account  by  a  medical  eye-witness  at  SalpStrifire,  Brit.  Med.  Journal,  Oct.  12, 
1878. 

2  N.  Y.  Medical  Journal,  May,  1872. 

s  Fat  and  Blood,  and  How  to  Make  Them.    Phila.,  1877. 

*  Practitioner,  June,  1870. 

6  Brain,  July,  1879.  «  Progrgs  Medical,  Ko.  8,  1879. 

^  By  Landouzy,  Saunders,  Anderson,  McLane  Hamilton,  Morton  and  otliers, 


392    DISEASES   OF  BRAIN  AND   NERVOUS  SYSTEM. 

have  passed  through  lives  of  great  disturbance,— as  prostitutes 
or  otherwise.  Their  attacks  may  be  frequent,  and  of  various 
duration  ;  and  they  may  be  voluntarily  induced  in  many  cases. 
In  several,  pressure  of  moderate  degree  upon  one  of  the  ovaries 
will  at  once  bring  on  a  paroxysm.  Three  stages  are  mentioned ; 
1st,  of  rigidity  ;  2d,  of  violent  convulsive  movements  (often  opis- 
thotonos)-^ 3d,  of  "emotional  attitudes."  During  the  latter, 
exhibitions  of  anger,  terror,  joy,  grief,  etc.,  succeed  each  other. 

Fig.  118. 


Hystero-Epilepsy.     (Bourneville.) 

Very  ^rm  pressure  upon  an  ovary,  which  appears  to  be  in  some 
cases  at  least,  the  main  source  of  reflex  irritation,  will  often 
terminate  the  attack.  Tlie  temperature  in  hystero-epilepsy  is 
never  so  high  as  it  often  is  in  true  epilepsy. 

As  has  been  already  observed  in  regard  to  hysterical  hemianes- 
thesia^ it  yet  remains  to  be  placed  beyond  doubt  how  much  of 
these  phenomena  may  be  due  to  physical,  and  how  much  to 
mental  impressions  and  communications.  In  any  case,  however, 
they  form  a  remarkable  chapter  of  medical  history. 


NEURALGIA. 

Definition. — Pain,  without  inflammation  or  other  disorder, 
except  that  of  the  nerve  or  nerve-centre  involved ;  literally,  nerve- 
pain. 

This  may  affect  any  of  the  sensitive  nerves.  It  is  also  some- 
times referred  to  parts  which  have  in  health  no  sensibility,  as  the 
heart,  stomach,  etc.  Different  names  are  given  according  to  its 
site.  Thus,  tic  douloureux  is  facial  neuralgia ;  hemicrania  (mig- 
raine), that  affecting  one  side  of  the  head ;  sciatica,  that  of  the 
hip ;  gastrodynia,  neuralgic  pain  in  the  stomach ;  pleurodynia,  in 
the  side.  Angina  pectoris  is  chiefly  a  neuralgic  affection  of  the 
heart. 

The  pain  is  generally  acute,  shooting  or  darting,  with  tender- 
ness of  the  part  upon  pressure.     There  is,  however,  no  heat  nor 


NEURALGIA.  393 

swolliiiij:,  nor  throljbing  of  the  Idood-vessols  in  puro  neuralgia. 
Complicated  cases  occur,  in  which  intlaniination  and  neuralgia 
exist  together;  and  inllamniation  of  t!\e  lihrous  neurilemma  may 
bo  the  immediate  cause  of  the  neuralgic  pain.  The  periodical 
cephalalgia  (sick  headache),  which  souk^  persons  are  subject  to 
nearly  all  their  lives,  and  the  tendency  to  which  may  be  hered- 
itary, is  not  a  jni-ye  ncniralgia;  but  tlie  pain  in  it  is  probably 
seated  in  the  cranial  nerves,  not  in  the  brain. 

Pathology. — At  least  three  sources  of  this  sort  of  pain  are  pos- 
sil)le.  1.  Local  disease  allectinL:;  a  nerve;  2.  A  morbid  state  of  a 
sensorial  7)('»-i'f-C('nire  ,•  8.  A  m()rl)id  condition  of  the  6foor7.  Neu- 
ralgia always  fixed  or  returning  in  the  same  spot  is  likely,  although 
not  certain',  to  depend  upon  a  fault  in  the  nerve  itself;  as,  e.  <j., 
neuroma  (tumor  of  a  nerve).  Radiating  pain  (although  possibly 
of  reliex  origin)  nuist  involve  at  least  part  of  a  nerve-centre. 
Flyiuiij  pains,  never  long-seated  in  one  part  of  the  body,  mostly 
are  due  to  a  defect  or  morbid  poison  (as  that  of  gout  or  malaria) 
in  the  blood. 

Treatment. — This  must,  of  course,  depend  upon  the  cause  or 
nature  of  the  case.  27c  doulourcitx  often  depends  upon  decay  of 
the  teeth  ;  if  so,  they  must  be  attended  to.  Other  purely  local 
neuralgias  require  local  treatment.  Electricity  has  often  been 
used  with  advantage.  Laudanum  or  paregoric,  applied  by  satu- 
rating a  rag  and  laying  it  upon  the  part,  covered  by  oiled  silk  to 
prevent  evaporation,  is  an  elHcient  local  anodyne.  So  is  chloro- 
form, similarly  applied  ;  it  is  very  pungent,  burning  like  mustard. 
Sinapisms  will  in  some  instances  relieve  promptly.  Mere  warmth, 
as  of  flannel  steeped  in  hot  water,  will  not  unfrequently  do  so. 
I  have  heard  of  the  pain  disappearing  upon  the  application  of 
half  of  a  cut  lemon  to  the  part  affected.  The  Chinese  use  oil  of 
peppermint,  locally  applied.  Dr.  Wright  asserts^  that  this  oil  is  a 
good  local  anaesthetic.  Drs.  Buzzard  and  Anstie  have  found  great 
benefit  from  the  constant  galvanic  current.^  On  some  portions 
of  the  body,  the  locally  anaesthetic  action  of  carbolic  acid'  may 
be  available.  I  prefer  it  to  be  diluted  more  or  less  with  camphor- 
ated oil.  Dr.  Keunion^  asserts  that  neuralgic  (and  other)  head- 
aches may  be  relieved  by  the  application  to  the  temple  or  behind 
the  ear  of  a  solution  of  bisulphide  of  carbon.  Dr.  Horvath's 
observations^  on  the  production  of  local  ana-sthesia  by  alcohol  at 
a  very  low  temperature  ( — 5°  C. )  may  probably  be  utilized  for 
the  treatment  of  some  neuralgias.  Equal  parts  of  chloral  hydrate 
and  camphor,  intimately  mixed  (Lenox  Browne),''  make  a  fluid 
reported  to  be  useful  as  an  anodyne  application.  It  may  be 
painted  on  the  part,  and  allowed  to  evaporate.  Winternitz  and 
others  have  relieved  tic  doidoureux  by  the  local  application  of  ice. 
Rubbing  for  a  few  minutes  with  saturated  tincture  of  aconite 
root,  until  the  skin  tingles ;  or  the  application  of  ointment  of 

1  Lancet,  Nov.  19,  1S70. 

2  The  Pr.ictitioner,  June,  1871.    Dr.  Buzzard  used  a  constant  current,  from  ten  or  fif- 
teen cells  of  a  Weiss'  battery. 

s  Bill,  Am.  Journ.  Med.  Sciences,  Oct.  1870,  p.  573. 

*  Brit.  Med.  Journal,  June  13,  1863. 

6  Centralblatt  fiir  die  Mediciuischen  Wisseuschaften,  1873. 

6  Brit.  Wed.  Journal,  March  7, 1874.  -  - 


394     DISEASES  OF   BRAIN  AND  NERVOUS   SYSTEM. 

veratria  (gr.  xx  in  Kj  of  lard)  may  be  used  in  severe  cases.  In 
obstinate  ones,  a  blister  may  be  applied,  dressed,  after  removal 
of  the  cuticle,  v^ath  two  grains  of  acetate  of  morphia,  diluted  with 
ten  grains  of  gum  Arabic.  Or,  most  prompt  usually  of  all,  solu- 
tion of  morphia  may  be  hypodermically  injected,  to  the  amount 
of  one-fourth  drachm  to  one  drachm  at  once.  Lelut'  declares  that, 
in  a  number  of  cases,  subcutaneous  injection  of  water  has  answered 
as  well  as  that  of  solution  of  morphia.  Drs.  Bartholow  and  Mat- 
tison  (after  Besnier,  1878)  treat  sciatica  by  deeply  injecting  chloro- 
form (a  few  minims)  near  the  affected  nerve-trunk.  Bartholow 
also  affirms  that  much  relief  may  be  given  by  the  local  injection  of 
pure  alcohol.  Smith'^  speaks  of  atropia,  subcutaneously  used  (/^ 
to  ^  grain)  as  a  specific  for  sciatica.  Dr.  W.  J.  Morton"'  affirms 
that  the  sparh  of  a  Holtz  electric  machine  will  often  cure  neural- 
gic pains  in  from  ten  to  twenty  minutes.  Sometimes  the  inhala- 
tion of  ether,  nitrous  oxide,  or  chloroform  is  resorted  to,  for  the 
relief  of  intense  neuralgic  pain.  Debility  predisposing  to  it,  in 
some  cases  warm  food  or  moderate  doses  of  an  alcoholic  stimulant 
will  give  relief.  On  the  other  hand,  liemicrania  has  sometimes 
been  cured  by  the  local  application  of  leeches ;  and  facile  neu- 
ralgia by  pressure  upon  the  primitive  carotid  of  the  affected  side. 
Of  anodynes  internally  used,  belladonna  has,  for  neuralgia,  the 
greatest  reputation.  It  will  not  quell  suffering  so  directly  as 
opium  or  morphia,  but  it  has  been  thought  more  entirely  to  do 
away  with  the  neuralgic  state.  For  this,  however,  iron^  espe- 
cially in  combination  with  quinia  or  strychnia,  is  the  most  effective 
medicine.  Cases  of  neuralgia  which  will  not  be  benefited  by  iron 
are  decidedly  exceptional.  Larger  doses  of  it  are  generally 
recommended  for  this  than  for  other  diseases  requiring  chaly- 
beates.  Quinine  is  particularly  wanted  in  neuralgias  of  malarial 
origin  (very  common);  and  strychnia  ornux  vomica  in  those  whose 
obstinate  persistence  depends  uiwn  great  loss  of  nervous  energy. 
Chloride  of  ammonium  is  recommended  by  Anstie  and  others. 
Aconite  may  be  very  effective,  but  requires  care  in  its  employ- 
ment. Five-drop  doses  of  the  tincture  have  been  given  safely 
in  severe  cases.  Hydrate  of  chloral^  in  doses  of  from  five  to  fifteen 
grains  or  more,  is  a  useful  anodyne  ;  more  powerful,  however,  in 
producing  sleep  than  in  relieving  pain.  Croton  chloral  hydrate 
has  been  given,  in  one  or  two  grain  doses  (Liebreich,  Falconer) 
beneficially  in  sciatica.  Oil  of  turpentine  is  said  (Begbie)*  to  be 
especially  remedial  in  periodical  cephalalgia.  Dr.  S.  M.  Bradley,* 
of  Manchester,  England,  recommends,  in  feeble  cases,  plios- 
phorus,  in  -^  grain  doses,  dissolved  in  ether.  It  will  be  safer  to 
begin  with  smaller  doses,  watching  the  effect.  Tonga  is  one  of  the 
newer  anti-neuralgic  remedies,  reported  well  of  by  S.  Einger  and 
others."  Everything  that  recuperates,  as  generous  diet,  change 
of  air,  sea-bathing,  etc.,  will  assist  in  curing  neuralgia,  when  it 

1  L'  Union  MSdicale,  Oct.  5.  1875. 

2  Allgemeine  Med.-Cent.  Zeitiing,  Feb.  16,  1881. 
s  N.  y.  Medical  Record,  April  2,  1881,  p.  371. 

4  Edinburgh  Med.  Journal,  Julv,  1871. 

0  British  Med.  Journal,  Feb.  28,  1874. 

6  Lancet,  March  6, 1880.    Half-ounce  doses  of  the  liquid  extract  have  been  given. 


DELIEIUM    TREMENS.  395 

is  cnnnoctod,  as  it  so  often  is,  with  anfcmia,  and  broken  health. 
Intractable  neuralgia  has  sometimes  been  treated  by  cZivmo?),  exci- 
sion, or  stretchinr/  of  tlie  nerve  involved.  Simple  division  often 
fails  to  eure.  Excision  of  a  portion  of  the  nerve  is  more  likely 
to  succeed.  Nerve-stretching  (liillroth,  18(59)  has  been  performed 
a  good  many  times,  for  neuralgia,  epilepsy,  tetanus,  etc.^  Von 
Nussbaum,  Callendcr,  Petersen  and  others  have  I'eported  several 
cures  of  neuralgia  by  it.  More  favor  has  been  shown  to  it  of 
late  than  to  neurotomy;  but  neither  is  to  be  thought  of  unless 
all  other  remedial  measures  fail.  The  same  may  be  said,  of 
course,  of  tying  the  primitive  carotid  artery ;  which  was  prac- 
tised successfully  in  an  obstinate  case  by  Dr.  F.  H.  Gross,  in  1880.^ 

Of  less  severe  measures  in  treatment  of  neuralgia,  the  direct 
application  of  high  heat  may  be  mentioned  ;  and  also  (McLane 
Hamilton)''  the  i-apidly  alternating  application  of  heat  and  cold. 
I  have  known  an  attack  of  severe  facial  neuralgia  to  be  relieved 
by  the  patient  sitting  or  lying  in  the  sunshine  for  half  an  hour. 

Sick  headache  is  evidently  mainly  a  neurosis,  and  yet  the  pain 
is  not  always  of  a  neuralgic  character.  In  some  persons  a  hered- 
itary proclivity  to  it  appears.  Certain  women,  especially,  are 
subject  to  attacks  every  one,  two,  or  three  weeks  (though  seldom 
at  regular  intervals)  from  puberty  to  the  cessation  of  the  menses. 
Relief  of  such  attacks  by  treatment  is  often  difficult  to  obtain. 
Early  retirement  to  bed  is  mostly  requisite.  If  acidity  of  stomach, 
or  nausea,  be  present,  magnesia,  or  bicarbonate  of  sodium,  or 
blue  pill,  may  be  useful.  As  nervine  remedies  for  sick  headache, 
quinine,  guarana  (10  to  15  grains  at  once),  citrate  of  caffein  (3  to  6 
grains),  chloride  of  ammonium  (10  to  20  grains),  SiViA  monobromated 
camphor  (from  2  to  5  grains)  have  been  much  lauded  ;  but  they 
will  often  fail  of  the  desired  effect. 

Odontalgia,  toothache,  is  sometimes  purely  neuralgic.  More 
often,  it  results  from  exposure  of  the  nerve  by  the  decay  of  the 
tooth.  Again,  it  may  attend  inflammation  of  the  jaw,  or  abscess 
at  the  root  of  the  tooth  affected.  For  toothache  from  exposed 
nerve,  creasote  is  a  certain  remedy.  Insert  carefully  into  the  hol- 
low a  plug  of  cotton,  wrapped  over  the  end  of  a  knitting-needle 
and  dipped  in  pvire  creasote.  If  the  latter  run  out  into  the  mouth 
(which  should  be  avoided  if  possible)  rinse  it  at  once  with  cold 
water.  Oil  of  cloves,  laudanum,  chloroform,  tobacco  smoke,  raw 
whisky,  and  acetate  of  lead,  introduced  into  the  hollow  of  the 
tooth,  will  also  generally  give  relief. 

DELIRIUM  TREMENS. 

Synonym. — Mania  apotil. 

Symptoms. — Sleeplessness,  debility,  tremors,  horror,  hallucina- 
tions ;  often  with  loss  of  digestive  power.  The  insomnia  is  a 
cardinal  symptom  ;  if  the  patient  sleeps  a  whole  night  he  recovers. 
Debility  varies  in  degree  in  different  cases  ;  in  a  first  attack  it  is 
not  always  great.     Tremor  is  nearly  always  present.     The  illu- 

1  Vogt,  Die  Nerven  Dehiiung,  etc.     Leipzig,  1877. 

2  N.  Y.  Medical  Kecord,  Dec.  25,  1880,  p.  727. 

3  rhila.  Med.  Times,  Sept.  4,  1875,  p.  771. 


396    DISEASES   OF    BRAIN   AND   NERVOUS   SYSTEM. 

sions  of  the  patient  are  wonderfully  real,  and  usually  dreadful. 
He  is  pursued  by  demons  or  beset  by  mortal  enemies ;  he  cannot 
bear  to  be  alone,  especially  in  the  dark.  Sometimes,  however, 
the  visions  are  indifferent,  or  even  amusing.  The  patient  may 
suppose  himself  to  be  well,  and  engaged  about  his  usual  avoca- 
tion ;  going  through  all  its  movements  in  pantomime,  though 
with  empty  hands. 

After  several  days  and  nights  of  sleeplessness,  prostration 
usually  increases ;  the  skin  grows  cold  and  clammy,  the  pulse 
weak  and  rapid,  the  voice  feeble,  and  the  patient  no  longer  in- 
clines to  move  about.  Death  must  result  if  sleep  be  not  obtained 
within  a  week,  or,  at  the  most,  two  weeks.  In  favorable  cases, 
a  sound  sleep  of  many  hours  comes  on  within  three  or  four  days ; 
the  patient  then  wakes  up  rational  and  well. 

Causes. — There  is  no  room  for  doubt  that  this  affection  may 
come  on  under  two  different  conditions  or  circumstances  ;  1, 
where  stimulants  are  suddenly  withdrawn  from  one  accustomed 
to  them ;  and  2,  while  their  use  in  excess  is  continued.  The 
second  class,  according  to  my  observation,  furnishes  the  most 
dangerous  cases. 

Treatment. — Old  as  this  disease  is,  it  is  yet  the  subject  of  great 
difference  of  opinion.  The  practice  which  early  training  led  me 
to  adopt,  consisted  in  the  moderate  use  of  stimulants  ("  tapering 
oft'")  and  of  opium,  with  concentrated  liquid  nourishment.  If 
the  patient  were  not  much  prostrated,  I  would  give  only  ale  or 
porter,  a  bottle  or  two  in  the  day ;  with  hop-tea  ad  libitum,  and 
a  grain  of  opium  every  three  or  four  hours.  The  latter  would 
be'increased,  if  sleep  were  delayed,  to  a  grain  every  two  hours  ; 
or,  as  a  maximum,  a  grain  every  hour.  Very  weak  cases,  accus- 
tomed to  spirits,  might  have  for  a  time  a  tablespoonful  of  whisky 
or  brandy  every  four,  three,  or  two  hours,  according  to  their  con- 
dition. Beef-tea  and  mutton-broth,  etc.,  seasoned  with  red  pep- 
per, are  preferred  as  diet.  In  an  obstinate  case,  I  have  seen  sleep 
follow  the  raising  of  a  blister  upon  the  back  of  the  neck.  Substi- 
tuting valerian  for  opium,  or  combining  the  fluid  extract  or  tinc- 
ture of  valerian  with  morphia  solution,  has  answered  well  in 
some  cases.  [F.  144,  145.]  Injection  of  laudanum  into  the  rec- 
tum is  occasionally  resorted  to. 

Other  modes  of  treatment  have  recently  been  urged. ^  1.  The 
expectant  treatment  of  Drs.  Dunglison  and  Laycock ;  giving  only 
strong  food  without  stimulantsor  opium.  2.  The  treatment  of 
Jones  of  Jersey,  by  tablespoonful  doses  of  tincture  of  digitalis. 
3.  That  by  the  internal  use  of  chloroform,  in  one  or  two  drachm 
doses  ;  or  equivalent  amounts  of  hydrate  of  chloral. 

The  expectant  treatment  will  no  doubt  do  very  well  in  mild  or 
moderate  cases.  From  what  I  have  seen,  I  should  fear  to  trust 
to  it  in  severe  or  threatening  ones. 

The  digitalis  treatment,  bold  as  it  seems,  has  a  good  deal  of 
positive  testimony  in  its  favor.  Dr.  A.  Wiltshire,  for  instance, 
reports'^  five  cases  cured  by  half-ounce  doses  of  the  tincture  of  digi- 

1  Dr.  Sutton  is  the  supposed  author  of  the  opium  dogma  (sleep  or  die)  in  delirium 
tremens.    Dr.  Ware,  of  Boston,  N.  E.,  first  protested  against  its  necessity,  1825-30. 

2  Lancet,  Aug.  27,  1870. 


METHOMANIA.  397 

talis.  Why  not  try,  as  some  do,  less  immense  and  yet  large  doses ; 
as,  half  a  drachm  or  a  drachm,  instead  of  half  an  ounce,  of  the 
tinctiu'e  every  three  or  four  hours?  Dr.  Sanders,  of  the  Royal 
Inlirmary,  Edinhurgh,  has  found  half-drachm  doses  to  do  very 
well  in  severe  cases. 

Dr.  E.  McClellan  and  others  have  reported  excellent  success 
with  one  or  two  drachm  doses  of  undiluted  chloroform.  The 
corrugated  stomach  of  a  spirit-drinker  will  probably  bear  the 
pungency  of  chloroform  better  than  another's.  Generally  only 
one  or  two  such  doses  of  it  are  said  to  be  required.  My  expe- 
rience with  the  internal  use  of  chloroform  leads  me  to  believe  such 
practice  perfectly  safe  at  least  ;  although  I  prefer  dilution  of  the 
chloroform.     It  is  worthy  of  further  trial. 

Dr.  Peacock,  of  St.  Thomas's  Plospital,  London,  reports  well 
of  bromide  of  potassium  in  delirium  tremens.  Dr.  A.  Flint,  also, 
uses  it  with  conlidence. 

JJt/drateof  Chloral,  from  its  great  power  as  a  hypnotic,  deserves 
careful  trial  in  this  disorder.  It  has  been  very  favorably  i-eported 
upon  by  a  number  of  physicians  both  in  Europe  and  in  this 
country.  Its  dose  in  delirium  tremens  should  be  usually  from 
30  to  40  grains,  repeated,  if  necessary,  every  hour  for  three  or 
four  times.  Dr.  Anstie  expressed  (Reynolds'  System  of  Med- 
icine, article  Alcolwlism)  the  decided  oi^inion  that  "bromide  of 
potassium  and  chloral  are  practically  the  only  drugs  we  need 
ever  employ  in  delirium  tremens."  Dr.  Balfour,  of  Edinburgh, 
gives^  forty  or  fifty  grain  doses  of  chloral-hydrate  ;  sometimes 
administering  from  100  to  120  grains  of  the  drug  in  all.  I  should 
fear  going  much  beyond  this,  in  view  of  the  proved  possibility 
of  very  large  doses  of  chloral  having  fatal  effects. 

Dr.  Lyons  and  others  speak  highly  of  the  effects  of  capsicum, 
in  80-grain  doses.  Hewitt,  of  Dublin,  has  cured  one  case  by  the 
application  of  the  ice-bag  to  the  spine.'-  Packing  in  a  wet  sheet 
is  sometimes  followed  promptly  by  sleep  and  recovery. 

The  large  majority  of  first  attacks  of  mania  a  potu  are  curable. 
Third  and  fourth  attacks  are  often  fatal,  or  are  followed  by  per- 
manent insanity. 

METHOMANIA. 

Definition. — The  disease  of  uncontrollable  or  irresistible  intem- 
perance. 

Synonyms. — Dipsomania ;  Oinomania. 

Varieties. — Periodical  or  paroxysmal,  and  chronic  or  persistent 
methomauia.  The  subject  of  the  first  may  be  temperate  for 
weeks  or  months,  and  then  will  abandon  himself  to  violent 
excess  for  some  days  or  for  a  week  or  two.  The  persistent 
methomaniac  is  constantly  intemperate,  so  long  as  the  opxjor- 
tunity  exists. 

Causes. — Hereditary  proclivity  exists  in  many  cases.  Wilful 
or  unwise  excess  is  the  cause,  of  course,  of  intemperance  in 
every  case.  To  designate  it  as  a  disease  is  not  at  all  to  deny 
the  accountability  of  those  who  voluntarily  incur  it ;  only,  thus, 

1  Lancet,  Feb.  1, 1879. 

2  Dublin  Med.  Press  and  Circular,  April  22,  1868. 

34 


398     DISEASES    OF    BRAI^'    AND  NERVOUS   SYSTEM, 

its  true  acquired  character  of  uncontrollahleness  (in  many  in- 
stances) by  the  will  is  indicated.  That  any  intrinsic  power  exists 
in  alcohol  employed  for  its proj:)er  needs  as  a  medicine,  and  in  proper 
quantities,  to  bring  on  intemperance,  I  do  not  believe.  I  have 
known  too  much  of  its  use  in  practice  in  low  fevers,  in  phthisis, 
and  many  other  conditions  of  debility,  not  to  be  sure  that  it  is 
only  when  used  in  excess,  or  out  of  place,  that  any  hankering  or 
slavish  demand  for  it  is  begotten  ;  unless  in  those  who  inherit  a 
morbid  proclivity  towards  it. 

Treatment. — No  safety  exists  except  in  seclusion  for  a  year  or 
two,  where  the  individual  cannot  obtain  stimulus,  and  is  not 
made  by  company  or  opportunity  to  desire  it.  Laws  should  be 
passed  (in  Pennsylvania,  and  in  some  other  places,  such  laws  do 
exist)  by  which  every  person,  proved  upon  inquiry  before  a  com- 
mission to  be  habitually  intemperate,  should  (like  a  lunatic)  be 
deprived  of  the  control  of  his  liberty  and  property.  Then,  in 
every  community  there  ought  to  be  institutions  where  a  safe  and 
homelike  retreat  could  be  had  for  a  sufficient  time  to  restore  self- 
control;  which,  I  repeat,  ought  to  be  never  less  than  a  year; 
better  two  years.  Several  such  institutions  have  now  been  in 
operation  for  a  considerable  number  of  years.  The  success  so 
far  obtained  in  these  retreats  has  been  quite  enough  to  justify 
fully  their  establishment  and  support  near  every  large  city. 

Medicinally,  bromide  of  potassium  is  likely  to  lessen  the  nerv- 
ousness of  those  from  whom  accustomed  stimulus  has  been  with- 
drawn. Quinine,  iron  and  other  tonics,  as  well  as  pepper  or  other 
stomachics,  may  be  required,  with  nourishing  and  easily  digest- 
ible diet.  The  best  situation  for  an  "inebriates'  retreat  "  must 
be  in  the  country,  where  rural  enjoyments  may  be  had,  with  but 
little  abridgment  of  personal  liberty. 

INSANITY. 

Definition. — Loss  of  control  of  the  will  over  the  mental  facul- 
ties or  impulses ;  intellectual,  emotional,  or  sensorial  derange- 
ment. 

Varieties. — 1.  Mania  ;  acute^  and  chronic ;  also  divisible  into 
intellectual  insanity  or  delusion,  emotional,  impulsive,  or  moral 
insanity,  and  illusional  derangement  or  hallucination.  2.  Mono- 
mania, or  partial  insanity;  e.  g.,  homicidal  and  suicidal;  lde])to- 
mania,  or  insane  propensity  to  steal ;  erotomania  (satyriasis, 
nymphomania)  or  uncontrollable  amatory  desire ;  pyromania, 
morbid  propensity  to  commit  arson,  etc.  3.  Melancholia.  4. 
Dementia;  i.  e.,  total  wreck  of  the  faculties,  or  imbeciht}^ 
Idiocy  is  congenital  imbecility. 

Premonitions. — By  noticing  these,  often  prevention  may  be  sug- 
gested and  effected.  Hardly  any  of  them  alone  may  be  sufficient, 
while  altogether  they  become  so.  1.  Headache,  not  accounted 
for  by  ordinary  causes,  and  continuing  for  days  or  weeks  together. 
2.  Irritability  of  temper,  not  previously  habitual.  3.  Unnatural 
hilarity  without  occasion.  4.  Depression  or  gloom,  not  justified 
by  any  event.     5.  Alternations  of  excitement  and  despondency, 

1  Puerperal  insanity  is  one  form  of  acute  mania. 


INSANITY.  399 

both  cxlromc.  G.  Any  pjroat  niodilication  of  the  natural  tempor 
or  habit  of  mind,  so  that  tlic  indivichial  becomes  the  opi)osite  of 
his  usual  self.  7.  Dislike  or  distrust  of  near  friends  and  family, 
without  any  reason  for  it. 

Diagnosis. — Alienation  from  his  own  accustomed  character 
and  disruption  from  rational  and  harmonious  relations  with  per- 
sons and  things  around  him— these  are  the  cardinal  elements  of 
the  insane  state.  This,  all  auihorities  admit  to  be  more  easily 
detected  or  discriminated  than  delincd.  The  old  legal  test,  that 
the  lunatic  must  be  incapable  of  knowing  right  from  wrong, 
has  been  given  up  ;  as  very  many  cases  of  emotional  or  "moral  " 
insanity  are  proved  to  exist,  in  which,  with  full  knowledge  of 
right  and  wrong,  the  morbid  impulse  is  irresistible  by  the  will. 
There  is  no  physical  test  of  insanity,  by  the  pulse  or  otherwise ; 
as  in  chronic  mania,  etc.,  all  the  organic  functions  may  go  on 
normally.  The  expression  of  the  face  is,  it  is  true,  nearly  always 
unnatural.  Perhaps  the  greatest  ditliculty  exists  in  monomania, 
unless  one  knows  the  peculiar  delusion  or  morbid  tendency  of  the 
patient,  as  upon  all  other  matters  he  may  be  sound.  Feit/ned  in- 
sanity is  generally  overacted  ;  sometimes  it  may  require  the  skill 
of  experts  to  expose  it.  Not  unfrequently  ancesthesia  may  be  used 
to  advantage  in  effecting  this  exposure  ;  on  coming  out  of  the 
state  of  unconsciousness  the  impostor  or  malingerer  will  betray 
himself. 

Prognosis. — More  than  half  of  first  attacks  of  insanity,  under 
good  management,  are  recovered  from.  With  each  repetition, 
the  hope  grows  less;  and  so  it  does,  also,  in  proportion  to  the 
duration  of  chronic  mania.  Sometimes,  however,  cures  occur  of 
those  who  have  been  insane  for  years.  Dementia  is  a  common, 
and  generally  hopeless,  termination  of  prolonged  chronic  mania 
or  melancholia.  Puerperal  mania  is  curable  in  a  large  majority 
of  cases.  Ordinary  acute  mania  varies  in  duration  from  a  week 
or  two  to  several  months.  Its  worst  form  is  the  "acute  delir- 
ious mania"  (Bell's  disease)  of  authors;  sudden,  chaotic,  and 
prostrating.  It  may  end  either  in  recovery,  in  lapsing  into 
chronic  mania,  in  dementia,  or  even  in  death  during  the 
attack.  Periodical  insanity  is  occasionally  met  with,  especially 
in  females. 

Causes. — These  are  numerous.  The  principal  ones  are  hered- 
itary predisposition,  injuries  of  the  head,  intemperance,  reverses 
of  fortune,  loss  of  friends,  and  domestic  troubles. 

Pathology. — Much  yet  remains  to  be  learned  of  this.  Subtle 
alterations  of  brain-structure  are  still  to  a  considerable  extent 
unrecognizable,  even  with  the  aid  of  the  microscope.  Two 
elements  in  the  pathology  of  insanity  have  been  distinctly  made 
out :  cerebral  hypercemia,  which  predominates  in  the  more  acute 
cases,  and  atrophy,  which  is  (either  quantitative  or  qualitative) 
present  in  nearly  all  those  which  are  chronic. 

Dr.  J.  B.  Tuke'  asserts  tliat,  of  all  portions  of  the  brain  found 
altered  after  death  in  those  dying  insane,  the  corp)ora  striata  are 
most  frequently,  and  the  cerebellum  the  least  often,  affected. 

1  Medical  Press  and  Circular,  Aug.  16, 1871. 


400  HEMOREHAGES. 

For  the  treatment  of  insanity  it  is  proper  to  refer  to  special 
treatises  upon  the  subject.  {See  Bucknill  and  Tuke,  Blanford, 
or  Maudsley  on  Insanity.)  The  advice  of  a  physician  in  nearly 
every  case  ouglit  to  be,  early  removal  to  a  well-conducted  asylum 
or  hospital  for  the  insane.  There,  security  and  the  prospect  of 
recovery  will  be  much  better  than  at  home  amongst  the  kindest 
of  friends.  In  the  treatment  of  insanity,  in  recent  times,  while 
the  use  of  medicine  (especially  tonics  and  hypnotics)  is  not 
neglected,  the  tendency  is  to  confide  a  great  deal  in  moral  or 
mental  treatment ;  i.  e.,  the  aggregate  of  personal,  local,  and 
circumstantial  influences,  which  in  an  asylum  can  be  arranged 
especially  with  a  view  to  the  most  favorable  effect  upon  its 
inmates.  The  placing  of  insane  patients,  not  violent,  under 
the  care  of  private  families  (as  at  Gheel  and  Clairmont)  has  been 
found  sometimes  productive  of  beneficial  results.  But  the 
abandonment  of  the  hospital  plan  (with  which  the  other  can  be 
combined)  altogether,  in  favor  of  this,  would  be,  no  doubt,  as 
great  a  mistake  as  the  often  urged  (Gardiner  Hill,  Conolly)  total 
abolition  of  mechanical  restraint. 

HEMOERHAGES. 

Varieties. — 1.  Active;  2.  Passive;  3.  Traumatic;  4.  Symp- 
tomatic ;  5.  Critical ;  6.  Vicarious.  Local  hemorrhages  are  also 
classified  according  to  the  organ  from  which  the  blood  escapes. 

Active  hemorrhages  are  those  in  which  determination  of  blood 
in  excess  to  the  part  precedes  tlie  bleeding.  Passive  hemorrhages, 
those  in  which  from  inaction  of  the  circulation,  or  passive  dilata- 
tion of  blood-vessels,  congestion  occurs  ;  or  in  which  the  coats  of 
the  vessels  give  way,  partly  from  the  blood  itself  being  incapable 
of  maintaining  properly  their  nutrition.  Tlie  idea  of  bleeding 
by  "  exlialation  "  without  rupture  at  least  of  capillaries,  is  now 
abandoned.  Occasional  escape  (Cohnheim)  and  migration  (Reck- 
linghausen) of  leucocytes,  is  admitted. 

Certain  persons  (sometimes  by  inheritance)  have  a  constitu- 
tional tendency  to  hemorrhages.  This  has  been  called  hsemo- 
philia  by  authors  (J.  W.  Legg).  A  slight  wound,  as  the  ex- 
traction of  a  tooth,  vaccination,  or  tlie  removal  of  a  wen,  may 
in  such  persons  be  followed  by  bleeding  to  death  ;  or  they  may 
die  from  epistaxis  or  some  other  spontaneous  hemorrhage.  It 
has  not  been  shown  whether  the  peculiarity  in  these  cases  consists 
in  a  deficiency  of  coagulability  in  the  blood,  a  defective  contrac- 
tility in  the  small  arteries,  or  (as  some  German  writers  have 
asserted)  an  excessive  violence  in  the  propulsion  of  the  blood  by 
the  heart.  Probably  abnormal  thinness  of  the  walls  of  the  blood- 
vessels has  the  most  to  do  with  it.  One  of  the  not  uncommon 
accompaniments  of  the  heemophilia  is  an  affection  of  the  larger 
joints,  with  pain,  swelling,  and  fever,  somewhat  resembling  artic- 
ular rheumatism.  Immerman^  asserts  that  members  of  the 
Jewish  race  are  particularly  liable  to  this  diathesis ;  also,  that 
it  is  more  often  met  with  in  Great  Britain  and  Germany  than 
elsewhere.  Authors  have  commonly  stated  that  women  who  are 
"bleeders  "  are  not  especially  liable  to  hemorrhage  after  delivery. 

iZiemssen's  Cycloptedia  of  Medicine,  vol.  xvii. 


nEMORRITAGES.  401 

Biirnor'  mid  Kohror,-  howovor,  have  brought  to  light  facts  show- 
ing that  dangerous  jjosl-jxirltim  hemorrliages  do  occur  in  women 
of  such  families.  Abortion  In  such  subjects,  also,  is  attended  by 
more  than  usual  peril. 

Brown-St'quardaud  Nothnagel,  on  the  basis  of  experimentation 
upon  animals,  assert  tiiat  mechanical  injuries  of  the  brain  pre- 
dispose to  pulmonary  hemorrhage  ;  and  Barety  {Lamxt^  May  2:^, 
1S74)  has  conlirmed  this  by  observation  iu  one  accidental  case  in 
a  human  subject. 

Traumatic  hemorrhages  are,  of  course,  all  produced  by  wounds ; 
coming  thus  under  the  department  of  surgery. 

Symptomatic  hemorrhages  are  met  with  in  many  diseases ; 
e.  g.,  cpistaxis  iu  typhoid  fever  ;  haimoptysis  in  consumption  ; 
vomiting  of  blood  in  ulcer  of  the  stomach  ;  bleeding  from  the 
bowels  in  piles,  etc. 

Critical  hemorrhages  are  occasional  terminations  of  febrile 
disorders ;  as,  yellow  fever,  remittent  fever.  Vicarious  hemor- 
rhage is  that  which  substitutes  one  which  is  normal  or  habitual ; 
e.  r/.,  spitting  of  blood  when  the  menses  have  been  suppressed  ; 
or  bleeding  at  tlie  nose  following  the  arrest  of  the  habitual  bleed- 
ing of  hemorrhoids. 

Epistaxis. — By  usage,  this  term  is  applied  only  to  bleeding  from 
the  nose.  In  young  persons,  especially  from  ten  to  fifteen  years 
of  age,  it  is  common,  and  if  moderate,  harmless  ;  seeming  often 
to  relieve  a  temporary  congestion  and  prevent  a  headache.  It  is 
more  often  seriously  troubresome  when  it  occurs  in  older  persons. 
Generally  it  is  from  one  nostril  only,  but  not  always. 

Treatment. — When  slight,  it  may  be  allowed  to  stop  of  itself  ; 
only  not  blowing  away  the  clot  that  forms  as  a  natural  plug.  If 
it  continue  so  as  to  threaten  an  injurious  loss  of  blood,  applying 
coldwater  to  the  forehead  and  nose,  or  ice,  there  or  to  the  back 
of  the  neck,  or  to  the  roof  of  the  mouth,  will  generally  stop  it. 
If  not,  a  plug  of  dry  cotton  may  be  introduced  and  left  in  the 
bleeding  nostril.  "Wetting  the  cotton  first  in  strong  alum-water, 
or  dilute  tincture  of  chloride  of  iron,  or  dipping  it  in  powder  of 
tannin  or  matico  may  make  it  more  eflective.  When  these 
measures  fail,  the  posterior  nares  must  be  plugged.  Either  the 
watch-spring  canula  may  be  used,  or  an  elastic  catheter,  having 
a  piece  of  Avaxed  ligature  or  twine  passed  through  its  eyelet-hole, 
may  be  carried  back  through  the  nostril  to  the  pharynx.  Then 
one  end  of  the  string  should  be  drawn  out  of  the  mouth  with 
forceps,  a  plug  of  cotton  listened  to  it,  and  the  other  end  drawn 
through  the  end  of  the  catheter  till  it  forces  the  plug  against  the 
posterior  orifice  of  the  nares.  Raising  the  arms  high  above  the 
head  is  a  popular  mode  of  endeavoring  to  stop  nose-bleeding. 
Dr.  Marvin,''  of  Geneva,  asserts  that  pressure  upon  the  facial 
artery,  where  it  passes  over  the  lower  jaw,  will  have  the  desired 
effect,  by  lessening  the  supply  of  blood,  to  the  nose.*    Hypoder- 

1  Wiener  Jredicinische  Wochenschrift,  Aug.  17, 1878. 

2  Archiv  fiir  Gynakologie,  Band  x. 
SGaz.  Med.  d'ltal.  Lonib.,  May  17,  1873. 

*  Tiemann,  of  New  York,  makes  Malayasi's  dilatable  india-rubber  bag  for  the  nostril. 
See  N.  Y.  Med.  Record,  Aug.  1.5,  1874. 

34*  2A 


402  HEMORRHAGES. 

mic  injection  of  ergo  tin  has  been  used  with  success  (Porak)  in 
serious  epistaxis. 

Bleeding'  from  the  Month. —This,  unless  when  ulcerative,  is 
generally  from  the  gums ;  as  in  scurvy.  It  is,  in  itself,  scarcely 
ever  serious  in  amount.  Considerable  bleeding,  sometimes  hard 
to  stop,  may  occasionally  follow  the  extraction  of  a  tooth. 

Treatment. — Borax  in  solution,  or  tannic  acid,  or  myrrh  and 
rose-water,  will  be  suitable  washes  for  the  bleeding  and  spongy 
gums  of  scurvy.  For  hemorrhage  after  the  removal  of  a  tooth, 
it  may  be  necessary  to  plug  the  cavity  with  lint  or  cotton  dipped 
in  tincture  of  chloride  of  iron,  or  creasote. 

Haemoptysis. — This  term  (spitting  of  blood)  is  generally  appHed 
to  hemorrhage  from  the  lungs,  bronchial  tubes,  trachea,  or  larj^nx. 
Ulceration  of  the  larynx,  trachea,  or  bronchi  may  produce  it,  not 
often  dangerously.  I  remember  one  case,  in  wliich  ulceration  of 
the  larynx  extended  so  as  to  open  the  carotid  arter}^  with  fatal 
result.  More  often  the  source  of  the  blood  is  the  lungs.  The 
diagnosis  of  this  is  of  great  consequence.  Much  alarm  ma}?^  be 
produced  by  the  spitting  of  blood,  whose  source  examination 
proves  to  be  the  posterior  nares.  This  may  not  be  supposed  by 
the  patient,  because  there  is  no  bleeding  anteriorly  from  the  nose. 
Between  pulmonary  hemorrhage  and  that  from  the  stomach,  the 
following  contrast  of  signs  exists  : — 

Frora  the  Lungs.  From  the  Stomach. 

Dyspnoea.  IN'ausea. 

Blood  coughed  up.  Blood  vomited. 

"     florid,  sometimes  frothy.  "     dark,  not  frothy. 

"     mixed  with  sputa.  "     mixed  with  food. 

In  a  majority  of  instances,  spitting  of  blood  from  the  lungs  is 
a  symptom  of  phthisis.  Cases  occur,  however,  sometimes,  espe- 
cially during  adolescence  and  early  maturity  (from  18  to  30  years 
of  age),  of  more  or  less  active  pulmonary  hemorrhage,  whose  sub- 
sequent history  disproves  a  tuberculous  origin  for  it.  In  these 
cases  there  may  be  immediate  danger  to  life,  more  probably  than 
in  the  frequent  bleedings  of  consumption.  Aneurism  of  the  aorta 
may  also  cause  hsemoptysis  by  mixture  of  the  tumor,  which  must 
cause  death.  This,  of  course,  is  comparatively  rare,  and  is  made 
known  by  signs  ah'eady  considered. 

Prof.  Baelz,  of  Tokio,  has  reported  (1880)  the  prevalence  in 
Japan  of  a  form  of  hsemoptj'sis,  unaccompanied  by  other  symp- 
toms, ascribed  to  a  gregarinoid  ixtrasite,  infesting  the  lungs.  He 
designates  the  affection  as  gregarinosis  jjulmonuni. 

Treatment. — For  active,  congestive  pulmonary  hemorrhage,  in 
a  young  and  robust  person,  it  was  formerly  a  common  practice 
to  take  blood  from  the  arm,  as  a  derivant  measure.  I  have  known 
this  to  succeed  perfectly,  with  no  subsequent  disadvantage.  But 
dry  cupping  over  the  chest  and  back,  with  sinapisms  to  the  legs, 
and  ice,  salt,  or  alum,  swallowed  slowly,  the  patient  being  at 
perfect  rest  in  bed,  with  the  head  and  shoulders  raised,  will  be 
sufficient  treatment  at  the  start  for  most  cases.  Then  we  may 
prescribe,  if  the  bleeding  continue  after  the  first  gush,  acetate  of 


HEMOURHAOES.  403 

lead  with  opium,  in  pill ;  say  a  cjrain  or  two  of  tho  former  with 
half  a  grain  of  the  latter,  every  four,  three,  or  two  hours,  as  the 
case  needs,  for  a  day  or  two  ;  or  wine  of  ergot,  half  a  (luidrachni 
every  two  hours  for  several  doses.  Applying  a  tourniquet,  or  some 
other  mode  of  ligation,  around  one  or  more  of  the  liml)S,  so  as  to 
retard  the  venous  How  of  blood  towards  the  heart,  has  sometimes 
had  a  good  eflcct  in  serious  hemorrhages. 

In  passive  or  tuberculous  haimoptysis,  rest,  with  the  head  and 
shoulders  propped,  is  necessai-y.  Ice,  salt,  and  alum,  alone  or 
together,  may  be  held  in  the  mouth,  and  swallowed  very  slowly, 
till  the  bleeding  has  stopped  for  the  time.  For  medicines,  in  the 
anremic,  gallic  acid  (gr.  x  to  gr.  xxx,  in  solution  with  aromatic 
sulphuric  acid)  [F.  14()],  oil  of  turpentine  (gtt.  x  to  gtt.  xx  in  mu- 
cilage) [F.  147J,  and  annnonio-ferric  alum  (gr.  v  to  gr.  x),  or  tinc- 
ture of  chloride  of  iron,  are  most  reconmiended.  Dr.  Anstie  *  and 
others  have  preferred  ergot,  or  ergotin,  hypodermically  or  by  the 
stomach,  as  most  efficacious.  Draschc,  of  Vienna,  introduced 
the  hypodermic  iisc  of  ergotin  for  internal  hemorrhages,  in  18(58 ; 
reporting  several  successful  cases.  Quinine  is  employed  by  some 
physicians  (Caro-')  to  "  quiet  the  action  of  the  heart  "  in  obstinate 
cases  of  hemorrhage.  But  dosing  with  styptics  in  consumption 
is  not  proper  for  every  trifling  discharge  of  blood.  They  are  suita- 
ble only  when  the  hemorrhage  itself  is,  or  threatens  to  be,  a  source 
of  additional  debility. 

Pulmonary  Apoplexy. — This  is  the  extremest  degree  or  result 
of  congestion  of^the  lungs ;  hemorrhage  occurring  into  the  air- 
cells,  and  obstructing  respiration,  sometimes  to  a  fatal  degree. 
Disease  of  the  heart  predisposes  to  this.  Its  attack  is  apt  to  be 
somewhat  sudden ;  there  is  great  dyspncea,  with  a  purple  coun- 
tenance, and  skin  rather  cold.  Percussion-resonance  is  dull.  On 
auscultation,  at  lirst,  a  bubbling  or  mucous  rAle  is  heard ;  after 
the  blood  coagulates,  no  respiratory  sound  at  all. 

Treatment. — If  diagnosticated  early,  in  a  person  of  tolerable 
strength,  venesection  should  be  performed  at  once.  Then  (or 
mstead  in  a  feebler  subject)  dry  or  cut  cups  should  be  applied 
extensively  between  the  shoulders  ;  followed  by  a  large  sinapism 
over  the  anterior  part  of  the  chest,  and  a  hot  pediluvium.  At 
the  same  time  the  reaction  which  should  aid  in  unloading  the 
oppressed  lungs  (the  object  of  venesection,  cupping,  etc.),  may 
need  to  be  favored  by  hot  drinks,  as  hot  lemonade,  cai'bonate  of 
ammonium,  or,  if  coldness  be  decided,  whisky  punch. 

Haematemesis. — Vomiting  of  blood  may  result  from  cancer,  or 
ulcer  of  the  stomach,  congestion  of  the  liver,  aneurism  of  the 
abdominal  aorta,  hysterical  disorder,  vicarious  menstruation,  etc. 
We  have  given,  above,  the  distinguishing  signs  between  it  and 
haimoptysis. 

Treatment. — This  must  be  varied  according  to  the  cause. 
Slight  ejections  of  blood  from  the  stomach  may  not  of  them- 
selves require  treatment — having  only  a  diagnostic  importance. 
In  ulcer  of  the  stomach  the  greatest  danger  may  occur,  except 
from  rupture  of  an  aneurism.     In  copious  haematemesis,  with 

1  Practitioner,  February,  April,  and  May,  1873. 

2  N.  Y.  Med.  Record,  June  1,  1874. 


404  HEMORRHAGES. 

absolute  rest  in  the  horizontal  position,  ice,  creasote  (one  or  two 
drops,  pro  re  nata)  in  solution  or  pill  [F.  81],  gallic  acid  [F.  146], 
oil  of  turpentine  [F.  147],  ammonio-ferric  alum,  or  tincture  of 
chloride  of  iron,  may  he  prescribed.  Food  must  be  given  in 
small  quantities,  and  concentrated. 

Hsematuria,— This  may  be  either  from  the  kidneys  or  from  the 
bladder.  If  the  blood  is  thoroughly  mixed  with  the  urine,  it  is 
probably  renal.  If  the  water  flows  off  nearly  pure,  and  the  blood 
follows  or  accompanies  the  last  portion,  it  is  vesical.  When  it 
follows  the  use  of  a  catheter  or  bougie,  independently  of  urina- 
tion, and  flows  in  a  stream  or  in  fresh  drops,  it  is  urethral  and 
traumatic. 

Renal  hemorrhage  may  attend  congestion  or  inflammation  of 
the  kidney;  or  cancer;  or  scarlet  fever  (generally  a  late  stage); 
or  the  irritation  of  a  calculus ;  or  that  of  cantharides  or  turpen- 
tine ;  or,  in  old  persons,  it  may  be  passive.  In  Egypt  a  parasite 
sometimes  produces  it,  the  distoma  (Bilharzia)  hcematohium. 

Treatment. — For  hemorrhage  from  the  kidney  sufficient  to 
deplete  at  all  seriously,  astringents,  as  gallic  acid,  tincture  of 
chloride  of  iron,  alum,  or  acetate  of  lead  may  be  used.  Dr. 
Upshur,  of  Richmond,  Va.,^  has  recorded  the  success  of  tincture 
of  guaiacum  (1  drachm  thrice  daily)  in  the  treatment  of  several 
cases  of  hsematuria.  Rest  is  important,  in  this  as  in  all  hemor- 
rhages, during  the  attack.  Bleeding  from  the  bladder  may  be 
treated  by  the  injection,  through  a  catheter,  of  solution  of  alum 
or  dilute  solution  of  creasote  (gtt.  j  in  fgj  of  water)  or  tannic 
acid  (gr.  x  in  f.5J). 

Intestinal  Hemorrhage. — A  frequent  cause  of  this  is  typhoid 
fever,  of  which  it  is  sometimes  symptomatic,  and  occasionally 
critical ;  ^.  e.,  the  commencement  of  convalescence.  The  same 
may  occur  in  yellow  fever,  or  in  remittent  fever  (less  often). 
Aneurism  of  the  aorta,  congestion  of  the  liver,  abdominal  can- 
cer, may  cause  it.  Blood  is  passed,  commonly  in  small  quan- 
tity, with  the  discharges  of  dysentery.  Aged  persons  not  unfre- 
quently  have  passive  hemorrhage  from  the  intestines.  Internal 
piles  are  very  often  productive  of  it.  The  blood  from  the  latter 
is  bright  red  ;  other  bleeding  from  the  bowels  is  darker  and  more 
mixed. 

Treatment. — Acetate  of  lead,  by  the  mouth,  with  opium,  or  by 
enema  ;  tannic  or  gallic  acid,  in  pill  or  by  injection,  in  solution  ; 
oil  of  turpentine ;  creasote  and  tincture  of  chloride  of  iron,  or 
ammonio-ferric  alum,  are  here,  as  in  the  other  hemorrhages  men- 
tioned, the  most  reliable  astringents.  For  bleeding  piles  special 
treatment  has  been  already  alluded  to.     (See  Hemorrhoids!) 

Vicarious  Hemorrhage. — The  most  frequent  instances  of  this 
are  in  connection  with  suppressed  menstruation.  Epistaxis, 
hsemoptysis,  hsematemesis,  renal  or  intestinal  hemorrhage  may 
occur,  but  it  is  most  apt  to  be  from  the  stomach  or  lungs.  The 
prognosis  in  this  form  of  hemorrhage  is  much  less  serious  than 
in  the  same  of  other  origin.  Its  treatment  should  be  addressed 
mainly  to  the  regulation  of  the  disturbed  or  interrui^ted  uter- 

1  N.  Y.  Med.  Record,  Dec.  13, 1879. 


DROPSIES.  405 

ine  function.  Warmth  to  the  lower  extremities  and  back  with 
such  cmnicnaiioyucn  as  each  (^ase  may  indicate,  will  generally  he 
required.  Aslrin!j;ents  are  to  be  avoided  in  vicarious  hemor- 
rhage, unless  it  be  in  excess  of  the  ordinary  menstrual  or  other 
suppressed  discharge. 

Uterine  Hemorrhage. — Besides  simply  excessive  menstruation, 
uterine  hemorrhage  may  be  from  placenta  prajvia  ("unavoidable 
hemorrhage");  abortion;  subsequent  to  delivery;  uterine  cancer ; 
ulceration  of  the  os  and  cervix  uteri;  tumors  within,  or  in  the 
walls  of  the  womb. 

Treatment. —  In  considerable  uterine  hemorrhage  of  either 
variety,  ergot,  in  substance,  Huid  extract,  or  wine,  is  likely  to 
be  of  use  by  promoting  contraction  of  the  womb.  Ammonio- 
ferric  alum  is  also  a  good  niedi(;ine  to  give  by  the  mouth  in  the 
.same  case.  Dr.  Robert  Lee  has  recommended  dujiUdh  in  menor- 
rhagia;  using  rather  large  doses,  but  not  continuing  them  long. 
Hypodermic  injection  of  atropid  (Tacke'),  gr.  ^^  twice  daily,  has 
been  used  with  success.  Locally,  ice  or  iced  water  may  be  (with 
care  not  to  chill  too  much)  applied  for  a  short  time  over  the  hypo- 
gastric region,  or  thrown  into  the  vagina.  Tincture  of  chloride 
of  iron,  in  solution,  will  have  a  powerful  eil'ect.  Tannic  acid  or 
matico  may  be  likewise  applied,  or  the  "  styptic  rod  "  of  tannic 
acid  and  cocoa-butter,  shaped  to  fill  the  vagina.  But  threaten- 
ing cases  (except  post-parhmi)  may  require  the  actual  tampon^  or 
plug  of  lint  for  the  whole  vagina,  or  the  sponge-tent  inserted  into 
the  OS  uteri  itself.  Stimulants  may  at  times  be  called  for,  to  pre- 
vent fatal  exhaustion  under  large  hemorrhage,  either  from  the 
uterus  or  from  any  other  organ.  Pressure  upon  the  aorta  has 
sometimes  been  resorted  to,  through  the  abdominal  walls,  in 
uterine  hemorrhage.  Many  practitioners  now  depend  most  upon 
injections  of  Iwt  water  (115°  to  120°  F.).  Other  measures,  suita- 
ble after  delivery,  belong  to  the  department  of  obstetrics. 

Habitually  excessive  mi  nstruation  requires  that  the  patient  so 
afiected  should  maintain  absolute  rest  from  the  beginning  of  the 
flow  till  its  cessation.  Iron  is  nearly  (not  quite)  always  indicated 
in  such  cases  through  the  interval ;  particularly  the  tincture  of 
the  chloride  of  iron. 

Internal  Hemorrhages  of  olscure  origin  may  sometimes  pro- 
duce sudden  death.  A  remarkable  instance  of  this  occurred  in 
the  case  of  Adelaide  Neilson,  the  actress,  in  1880.  Writhing 
with  pain  from  a  gastralgic  attack,  she  suddenly  went  into  a 
state  of  syncope,  and  died.  Post-mortem  inspection,  by  Brou- 
ardel,  showed  that  death  was  caused  by  the  rupture  of  a  vcmcose 
vein  in  the  left  Fallopian  tube ;  from  which  two  quarts  and  a 
half  of  blood  had  passed  into  the  peritoneal  cavity.^ 

DROPSICAL  AFFECTIONS. 

"Varieties. — 1.  (Edema,  local  infiltration  of  connective  tissue 
with  scrum.     2.  Anasarca,  general  cellular  dropsy.     3.  Hydro- 

1  Berlin  Klin.  V/ochensclir.,  No.  6,  1881. 

2  London  Times,  Aug.  26,  IdSO. 


406  DROPSIES. 

cephalus.  4.  Hydrothorax.  5.  Hydropericardinm.  6.  Ascites.  7. 
Other  local  dropsies ;  as  Ovarian  dropsy,  Hydronephrosis,  Hydro- 
cele of  the  testis,  etc. 

Causation  and  Pathology. — Obstruction  to  the  venous  circula- 
tion, arrest  of  excretion,  and  excess  of  water  in  the  blood,  are 
the  three  cardinal  elements  of  the  pathological  causation  of 
dropsy.  Either  one  may  induce  it.  Disease  of  the  heart,  or  of 
the  liver,  brings  on  dropsy  by  venous  obstruction.  Disease  of 
the  kidney,  or  the  action  of  cold  and  wet  upon  the  skin,  may 
produce  it  by  checking  excretion.  "Wasting  diseases  are  liable 
in  their  advanced  stages  to  oedema  and  anasarca,  on  account  of 
the  watery  state  of  the  blood. 

Acute  general  dropsy  results  from  the  powerful  impression  of 
cold  and  wet,  or  of  the  scarlet-fever  poison,  upon  the  system, 
suppressing  both  the  action  of  the  kidneys  and  that  of  the  skin 
at  once.  Its  most  common  form  is  anasarca ;  but  it  may  take 
the  form  of  ascites,  hydrothorax,  or  even  hydrocephalus.  When 
from  cold  and  wet,  it  is  much  more  curable  (especially  anasarca 
or  ascites)  than  similar  dropsy  of  visceral  origin,  e.  g.,  from  disease 
of  the  heart.  Albuminous  urine  is  quite  common  in  acute  gen- 
eral dropsy. 

Hydrocephalus^  Hydropericardinm,  and  Hydrothorax  have  been 
already  sufficiently  considered. 

Ascites  is  peritoneal  dropsy ;  accumulation  of  water  in  the 
abdomen.  The  causes  of  this,  of  greatest  frequency,  are  cir- 
rhosis of  the  liver  and  disease  of  the  kidney.  It  may  also  fol- 
low obstruction  of  the  portal  vein  by  cancer,  or  general  obstruc- 
tion of  the  circulation  from  disease  of  the  heart,  aorta,  or  spleen; 
and  it  is  sometimes  ascribed  to  chronic  peritonitis. 

Symptoms  and  Diagnosis. — Often  with  emaciation  of  the  face, 
neck,  and  arms,  there  is  great  enlargement  of  the  abdomen.  When 
this  is  far  advanced,  orthopnoea  exists,  from  pressure  upon  the 
diaphragm.  The  patient  is  generally  weak,  with  poor  appetite 
and  deficient  rest  at  night. 

On  inspection,  in  the  upright  posture,  the  fulness  is  greatest  in 
the  lower  part  of  the  abdomen ;  when  recumbent,  it  spreads 
evenly;  on  one  side,  it  falls  over  that  way.  Palpation  will  make 
evident  fluctuation,  especially  when  one  hand  is  placed  on  one 
side  of  the  abdomen  and  the  other  strikes  gently,  at  a  distance 
of  a  few  inches.  Percussion  discovers  resonance  above  and  about 
the  umbilicus,  the  intestines  rising  there  upon  the  fluid  to  the 
surface  under  the  abdominal  walls.  Elsewhere  the  sound  is  dull, 
even  flat. 

The  amount  of  fluid  in  ascites  is  sometimes  immense  ;  as  much 
as  twenty-five  pints  have  been  withdrawn  at  once  by  tapping. 
It  is  generally  clear,  pale  yellow  or  colorless,  albuminous  and 
alkaline. 

Ovarian  Dropsy. — Leaving  the  history  of  this,  as  belonging  to 
the  special  department  of  diseases  of  women,  it  is  right  to  state 
that  its  diagnosis  is  important,  but  not  always  easy.  Like  ascites, 
it  produces  abdominal  enlargement,  with  dulness  on  percussion 
and  fluctuation.  The  most  nearly  constant  points  of  distinction 
are,  that  the  ovarian  tumor  begins  somewhat  on  one  side,  and 
only  by  degrees  becomes  symmetrical ;  its  shape  is,  throughout, 


DROPSIES.  407 

more  j^lobular  anrl  coherent,  and  altered  less  by  chanj^es  of  posi- 
tion ;  and  the  intestines  do  not  float  up  above  the  umbilicus  so 
as  to  make  a  clearness  of  percussion-resonance  there.  The  i)ro- 
grcss  of  ovarian  dropsy  is  usually  slower,  and  is  attended  by  less 
proportionate  depression  of  the  general  health.  The  Jhdd  of 
ovarian  C3'sts  is  peculiar,  and  different  from  that  of  ascites  ;  even 
when  not  clear,  it  lacks  the  light  straw  color  of  the  latter.  Dr. 
T.  M.  Drysdale,  of  Pbiladelpbia,  has  pointcsd  out  the  existence 
in  it  of  certain  (iranular,  non-nucleated  cells,  which  arc  character- 
istic. Acetic  acid  causes  the  granules  to  become  raoi'e  distinct, 
and  the  cell  to  become  more  transparent.  Such  cells  may  be  found 
in  other  cysts,  elsewhere  in  the  body;  but  not  in  ordinary  ascites.^ 

Treatment  of  Dropsy. — Acute  general  dropsy,  from  suppression 
of  the  action  of  the  skni  and  kidneys,  should  be  treated  by  active 
purgation  and  the  use  of  diuretics.  Jalap  and  cream  of  tartar 
(gr.  X  of  the  former  with  5ij  to  3iv  of  the  latter)  every  day  or  two, 
Avill  answer  well  for  catharsis.  The  diuretics  most  satisfactory 
are  the  infusion  of  juniper  berries  (a  pint  daily),  acetate  of  potas- 
sium, citrate  of  potassium,  squills,  and  sweet  spirits  of  nitre  [F. 
37,  38,  39,  40].  Infusion  of  buchu  is  a  favorite  adjuvant  vehicle 
for  the  stronger  diuretics.  Citrate  of  caftein  (Gubler)''  has  acted 
"well  in  several  cases  of  cardiac  dropsy,  in  4  to  6  grain  doses.  In 
too  large  dose,  it  may  cause  vomiting.  When  the  patient  is  hard 
to  purge,  elaterium  may  be  given,  in  i  gr.  doses,  every  four  hours 
till  it  operates. 

Murchison  reports  favorably  of  the  use  of  digitalis  both  inter- 
nally and  externally,^  in  ascites.  Jaborandi  (or  pilocarpin)  by 
inducing  copious  perspiration,  gives  promise  of  being  an  impor- 
tant remedy  in  dropsy. 

Ascites,  or  other  dropsy,  from  disease  of  any  of  the  great 
organs,  kidneys,  liver,  or  heart,  being  less  curable,  and  attended 
by  greater  general  debility,  needs  more  economy  of  strength. 
No  doubt  exists  that  real  harm  may  be  done  by  the  routine  of 
repeated  severe  purging  and  plying  with  diuretics.  The  one  may 
render  the  blood  thinner  and  aggravate  the  constitutional  disease, 
while  the  others,  failing  to  remove  the  fluid  by  secretion,  may 
even  irritate  the  kidneys  to  the  point  of  suppression  of  their  action. 
Nourishing  concentrated  food,  tonics,  anodynes,  etc.,  may,  in 
visceral  dropsy,  be  of  more  importance  than  diuretics.  Of  co'urse 
it  is  desirable  to  lessen  the  accumulation  of  fluid ;  but  the  effects 
of  the  remedies  used  must  be  observed,  and  one  symptom  must 
not  be  allowed  to  overshadow  the  rest.  Sigrist  and  Popoff",  Eus- 
sian  physicians,  have  found  faradization  of  the  abdominal  walls  to 
produce  diuresis  to  a  sufficient  amount  to  cause  great  relief  iu 
ascites.^ 

■^yhen  enormous  distention  makes  rest  impossible,  almost  pre- 
venting breathing,  it  is  necessary  to  relieve  it  by  any  possible 
means.  Then  purging,  as  by  elaterium,  should  diuretics  fail, 
must  be  resorted  to.     Or,  if  the  patient's  stomach  or  general 

1  Foulis  and  Knowsley  Thornton  have  described  a  different  kind  of  granulated  and 
nucleated  cell  as  observed  in  malignant  ovanan  tumors. 

2  Practitioner,  Jan.,  1879,  p.  24. 

3  Brit.  Med.  Journal,  July  17,  1872. 

*  N.  Y.  Med.  Record,  from  Vratch,  No.  9,  1880. 


408  DROPSIES. 

strength  will  not  bear  that,  tapping  is  called  for.  Some  patients 
require  this  many  times. 

The  operation  is  best  performed  while  the  patient  is  lying  down, 
upon  the  side,  near  the  edge  of  the  bed.  A  trocar  and  canula 
are  introduced  half  way  between  the  pubes  and  the  umbilicus, 
and  the  fluid  is  drawn  out  through  the  canula.  Dr.  T.  G.  Mor- 
ton,^ of  Philadelphia,  has  designed  an  improvement  of  the  ordi- 
nary canula,  by  adding  near  its  upper  end  a  short  silver  tube, 
upon  which  india-rubber  tubing  may  be  attached.  Thus  fluid 
may  be  conveyed  away  in  any  desired  direction  ;  the  extremity 
of  the  canula  being  closed  with  a  plug.  Lastly  a  bandage  (with 
a  compress)  is  applied  firmly  around  the  abdomen.  Some  practi- 
tioners favor  keeping  open  the  orifice  with  a  slip  of  lint,  to  main- 
tain drainage.  If  no  local  irritation  occur,  threatening  peritonitis 
in  consequence,  this  may  be  a  serviceable  measure.  If  the  bolder 
practice  of  injecting  iodine  after  tapping  (as  in  hydrocele)  should 
he  thought  of  in  any  instance,  it  must  be  in  that  of  simple  peri- 
toneal dropsy,  uncomplicated  by  serious  visceral  disease.  Dr. 
Reginald  Southey^  has  reported  success  with  the  insertion  of  a 
fine  canula  for  gradual  drainage,  after  puncturing  the  abdomen 
with  a  needle-trocar.  From  ten  to  twenty  ounces  of  fluid  passing 
away  through  the  canula  per  hour,  the  abdominal  walls  and 
viscera  adjust  themselves  safely  to  the  diminution  of  pressure, 
without  needing  the  application  of  a  bandage. 

Sometimes  oedema  of  the  lower  limbs  and  scrotum  becomes  so 
great  as  to  cause  great  inconvenience.  Then  the  fluid  may  be 
let  out  by  making  a  number  of  small  punctures  with  an  abscess 
lancet  or  small  pointed  bistoury.  Dr.  Handfield  Jones  recom- 
mends^ a  single  puncture  in  each  leg,  with  a  trocar,  leaving  the 
canulas  in  to  drain  for  several  hours.  The  only  drawback  to  this 
practice  is  the  possibility  of  erysipelatous  inflammation  about 
the  punctures.  Such  danger  will  not  be  at  all  great  if,  imme- 
diately after  the  operation,  the  parts  be  soothed  by  bathing  or 
anointing  the  skin  with  diluted  glycerin  (f^j  in  f§j  of  rose-water), 
or  cold  cream  (ung.  aq.  ros.),  orglyceramyl  (glycerin  and  starch) 
[F.  148]. 

For  the  treatment  of  ovarian  dropsy,  the  reader  is  referred  to 
works  upon  gynaecology  and  surgery.  I  may  only  state  my  con- 
viction that  preliminary  tapping  is  advantageous  in  many  cases 
for  which  ovariotomy  is  anticipated.  Reasons  for  this  are :  1. 
It  is  a  partial  test  of  the  endurance  of  the  patient's  system. 
Should  peritonitis  follow  tapping,  we  may  be  sure  that  the  prognosis 
of  the  larger  operation  would  have  been  unfavorable.  2.  It 
furnishes  a  sort  of  preparation  for  ovariotomy;  by  accustoming 
the  abdominal  contents,  including  the  peritoneum,  to  a  change 
of  bulk  and  pressure.  Moreover,  in  a  few  instances,  the  cure  of 
ovarian  dropsy  has  followed  the  operation  of  tapping  alone.  Yet 
it  is  right  to  add,  that  several  of  the  most  eminent  ovariotomists 
have  pronounced  their  judgment  very  decidedly  against  tapping, 
as  a  rule.*    When   there  is  reason  to  believe  a  compound   or 

1  Philada.  Medical  Times,  May  30,  1874. 

2  Lancet  Aug.  10, 1878.  3  Practitioner,  April,  1871. 

*  See  an  interesting  discussion  (from  the  Lancet,  Jan.  15,  1881)  in  ttie  Am.  Journal 
of  Med.  Sciences,  April,  1881,  p.  579. 


VARIOLA.  4U9 

niultilocular  tumor  (polyc3^st)  to  l)e  present,  it  certainly  ought 
never  to  be  tapped  unless  ovariotomy  is  immediately  to  follow 
(Goodell). 

ZYMOTIC    DISEASES. 

VAEIOLA. 

Sjmonym.  —  Small-iwx.  Varieties.  —  Discrete  and  confluent  ;* 
also,  varioloid,  or  modiiied  small-pox,  after  vaccination. 

Symptoms  and  Course. — Stages:  These  are,  hK-uhation, iirimary 
fever,  eruption,  secondary  fever,  and  desquamation.  The  incubation 
(period  between  exposure  to  the  contagion  and  beginning  of  the 
attack)  lasts  about  twelve  days.  The  first  symptoms  are  languor, 
headache,  vomiting,  and  severe  pain  in  the  back ;  soon  developing 
into  fever.  On  the  third  day  of  this,  pimples,  at  first  small  and 
red,  appear,  first  on  the  face,  then  on  the  neck,  arms,  trunk  and 
lower  limbs.  These  papules  become  vesicles,  and  then  pustules ; 
suppurating  perfectly  by  the  ninth  day  of  the  fever.  Then  they 
flatten  and  scab.  Four  or  five  days  later,  about  the  fourteenth 
day  of  the  fever,  these  scabs  begin  to  fall  off".  Desquamation  is 
commonly  completed  by  the  end  of  the  third  week  of  the  attack. 
To  recapitulate:  there  are,  after  about  twelve  days  of  incubation, 
three  of  primary  fever,  six  or  seven  for  the  coming  out  and  matur- 
ing of  the  eruption,  four  or  five  for  its  scabbing,  and  six  or  seven 
for  desquamation. 

These  periods  vary  somewhat ;  and  the  severity  of  the  disease 
depends  mostly  upon  the  amount  of  the  eruption.  This  makes 
the  ditterence  between  the  discrete  (scattered,  separate)  and  con- 
fluent small-pox.  Even  the  primary  symptoms  are  generally 
worse  in  the  latter.  The  secondary  fever,  connected  with  the  full 
development  of  the  eruption  (about  the  eleventh  day  of  the 
disease),  is  much  the  most  severe  in  the  confluent.  The  suffering 
of  the  patient  is  great,  even  extreme,  in  this  form,  the  whole 
surface  of  the  body  being  covered  with  inflamed  pustules.  Even 
the  eyes,  mouth,  and  throat  may  be  invaded.  Blindness  some- 
times follows ;  and  I  knew  of  one  case  in  which  the  eruption  in 
the  throat  proved  fatal  by  obstruction  of  the  breathing  and  swal- 
lowing. A  peculiar  and  disagreeable  odor  emanates  from  the 
body  in  continent  cases. 

Malignant  small-pox  is  simply  a  violent  form  of  it  characterized 
by  rapidity  and  extreme  prostration,  with  or  without  extensive 
pustulation.  The  eruption  in  it  is  sometimes  attended  by  lividity 
of  the  skin.  Delirium  is  common,  and  a  typhoid  stupor  may 
exist. 

After  small-pox,  abscesses  in  various  parts  of  the  body,  hard 
glandular  enlargements,  ulceration  of  the  cornea,  suppuration  of 
the  ear,  pneumonia,  or  pyoemia  may  occur. 

The  danger  to  life  in  this  disease  is  always  serious.  Before 
vaccination  was  introduced,  thousands  died  annually  from  small- 
pox. 

'  Hemorrhagic  small-pox.  Las  been  occasionally  described ;  it  must  be  very  uncommon. 
35 


410  ZYMOTIC    DISEASES. 

Of  those  attacked,  1  in  8  died  ;  in  infancy,  1  in  3.  Dr.  Lettsom, 
of  London,  estimated  that  210,000  died  every  year  from  it  in 
Europe  before  the  time  of  Jenner ;  45,000  annually  in  Great  Britain 
and  Ireland  alone. 

In  Audubon's  biography  it  is  stated  that  in  1837  150,000 
Mandan  Indians  died  of  small-pox  ;  leaving  only  27  of  the  tribe. 
Catlin  asserts  that  of  12  million  American  Indians  6  million  have 
been  destroyed  by  small-pox.  In  Philadelphia,  between  1860  and 
1870,  the  mortality  was  1  death  in  6.6  cases  of  the  disease.  In 
the  year  from  August  1871  to'  August  1872,  4417  deaths  occurred 
in  Philadelphia  from  small-pox.  In  the  year  1879,  not  a  single 
death  from  it  was  reported. 

Causation. — There  is  no  disease  more  certainly  contagious  than 
variola.  Generally  either  contact  or  approach  within  a  few  feet 
seems  necessary  for  its  conveyance  ;  but  I  have  met  with  one 
instance  in  which  it  must  have  traversed  the  high  walls  of  an 
inclosed  public  institution,  attacking  an  inmate  who  had  not  left 
the  house  for  ten  years,  and  without  the  admission  of  any  one 
who  could  have  brought  it.  In  the  large  majority  of  cases,  small- 
pox occurs  but  once  in  a  lifetime.  Exceptions  are  well  known, 
however  ;  some  in  which  the  same  person  has  had  it  three — it  is 
said  even  five  times.     Louis  XY.  died  of  a  second  attack. 

Treatment. — The  preliminary  symptoms  of  small-pox  do  not 
differ  from  those  of  most  other  acute  disorders,  except  that  the 
headache,  pain  in  the  back,  and  vomiting  are  apt  to  be  more 
severe.  In  that  stage,  rest  in  bed,  after  a  warm  mustard  foot- 
bath, and  drinking  hot  lemonade  to  promote  full  reaction,  will  be 
enough.  The  fever  calls,  first,  for  a  cooling  laxative  dose,  as 
Eochelle  salt  or  citrate  of  magnesium.  Then,  refrigerant  diapho- 
retics will  be  in  place  ;  as,  neutral  mixture  [F.  149, 150],  effervescing 
draught,  or  liquor  ammonii  acetatis;  the  first,  if  the  stomach  be 
good  and  the  boAvels  slow  to  act ;  the  second,  if  nausea  or  vomiting 
continue  ;  the  third,  if  the  bowels  be  free  and  the  fever  low  in 
type.  No  cutting  short  of  small-pox  is  possible  ;  it  is  a  self-limited 
disease.  There  is  no  specific  remedy  for  it ;  we  can  palliate  it 
only,  and  conduct  the  patient  through  it.^ 

^o  decided  is  the  tendency  to  exhaustion  of  the  system  in  severe 
small-pox,  that  early  support  by  concentrated  liquid  nourishment 
must  be  the  general  rule.  As  in  other  acute  illness,  appetite  and 
digestive  power  are  almost  lost.  Milk,  however,  in  small  quanti- 
ties often  (one  or  two  tablespoonfuls  every  two  or  three  hours) 
and  chicken  or  mutton  broth  or  beef-tea  may  be  given.  Other 
sick  diet,  as  gruel,  arrowroot,  toast- water,  etc.,  may  do  during 
the  primary  fever.  But  a  good  many  cases  will  require  even 
wine-whey  or  brandy  punch  in  the  second  and  third  weeks ; 
malignant  cases,  perhaps,  in  the  first  week.  Quinine  should  go 
with  these,  in  tonic  doses  ;  e.g.,  one  or  two  grains  every  three  or 
four  hours.  An  opiate  at  night  is  often  serviceable,  especially  in 
the  confluent  form.  Saracenia  purpurea  is  of  no  use  whatever  in 
small-pox. 

1  Dr.Schwenniger  (Berlin  Klin.  Woclienschrift,  25  Nov.,  1872)  asserts  that  large  doses 
of  quinine  in  the  premonitory  stage  lighten  the  attack. 


VACCINATION.  411 

Drs.  Znel^or  and  Nagol  recommend  highly  xyhl^  in  ten  or  fifteen 
drop  doses,  four  tinn;s  daily/  The  latter  reports,  under  its  use, 
only  four  deatiis  among  thirty-four  very  bad  cases.  Where  tlie 
throat  is  much  alfected,  tincture  of  chloride  of  iron,  in  glycerin, 
has  been  found  to  do  good. 

An  important  object  often  is  to  prevent  the  'pitting^  of  the  face. 
Three  plans  are  resorted  to :  1.  To  abort  the  vesicles.  2.  To 
sootlie  and  mitigate  the  inflammation  ccmnected  with  them.  3. 
To  exclude  air  and  light  during  the  scabl)ing  and  desquamation. 
The  first  of  these  ends  is  sought  by  touching  each  pimple  on  the 
face,  on  the  fourth  or  fifth  day  of  the  attack,  with  a  point  of 
lunar  caustic.  Soothing  inflammation  is  aimed  at  by  covering 
tlie  whole  face  duruig  the  first  week  with  a  soft  poultice  of  ])read 
and  milk,  flaxseed  meal,  or  slippery  elm  bark.  Exclusion  of  the 
light  may  be  attained  by  gold  leaf;  of  air,  by  mercurial  ointment 
or  collodion,  softened  by  adding  -^th  part  of  glycerin  before  it  is 
painted  upon  the  face.  Dr.  Leach,^  of  Philadelphia,  employs 
white-lead  painty  thinned  with  linseed  oil,  and  applied  early  with 
a  camel's-hair  pencil. 

How  are  we  to  choose  ?  I  would  begin  by  touching  the  worst 
papules,  on  their  second  day,  with  nitrate  of  silver.  Then  poul- 
tice the  whole  face  for  four  or  five  days,  till  the  pustules  flatten 
and  umbilicate.  Lastly,  apply  the  collodion,  softened  by  the 
addition  of  glycerin,  with  a  camel's-hair  pencil,  over  each  pus- 
tule, thickly  enough  to  make  an  artificial  cuticle  ;  which  may  be 
renewed  every  day  or  two,  until  desquamation  has  been  com- 
pleted. 

The  scquelce  of  small-pox  must  be  treated  as  they  arise  ;  by  the 
opening  of  abscesses,  improving  the  tone  of  the  system  by  iron, 
etc.  Great  care  is  needed  in  convalescence  from  this,  as  from 
other  acute  (especially  eruptive)  diseases,  not  to  allow  exposure 
to  sudden  changes  or  extremes  of  temperature.  The  danger  of 
contracting  pneumonia,  pleurisy,  or  bronchitis  is,  at  such  times, 
much-  greater  than  usual. 

Varioloid:  Modified  Small-pox. — In  those  who  have  been 
vaccinated,  while  the  lialnlity  to  be  affected  by  the  virus  of 
small-pox  is  in  most  cases  removed,  in  a  few  the  disease  is  taken, 
on  exposure,  in  a  milder  form.  The  primary  fever  is  rather  less 
severe,  the  eruption  is  more  scattered,  the  pustules  are  not  so 
deep  nor  so  much  inflamed,  they  scab  sooner  and  very  rarely  pit; 
and  there  is  no  secondary  fever.  Varioloid  is  seldom  flital.  Its 
treatment  should  be  essentially  the  same  as  that  of  small-pox ; 
only  there  is  less  often  need  of  special  measures  to  prevent 
marking  of  the  face. 

VACCINATION. 

The  ancient  practice  of  inoculation'^  with  small-pox,  while  it 

1  Philada.  IMcd.  Times,  1872. 

2  Inoculation  was  introduced  into  England  from  the  East  by  Lady  JUary  Wortley 
Montagu  in  1718.  An  account  of  it  had  been  published  in  England,  in  1714,  by  Dr. 
Tiraoni,  of  Constantinople.  Dr.  Boylston,  of  Ifeston,  brought  it  into  practice  in  this 
country  in  1721.  Dr.  Jenner's  first  vaccination  from  arm  to  arm  was  performed  in 
1796.  Vaccination  was  tirst  performed  in  America  and  Austria  in  1799;  in  France  and 
Spain  in  1800 ;  in  Italy,  Russia,  Denmark,  and  Sweden,  1801 ;  in  India,  1802. 


412  ZYMOTIC    DISEASES. 

was,  by  the  mildness  of  the  attack,  nearly  always  protective  of 
the  individual,  at  the  same  time  propagated  the  disease,  multiply- 
ing the  amount  of  its  virus.  Jenner's  introduction  into  profes- 
sional practice  of  inoculation  with  the  virus  of  cow-pox,  known 
before  his  time  among  dairymen,  has  greatly  abridged  not  only 
the  destructiveness,  but  the  prevalence  of  variola. 

"Whether  "vaccinia,"  or  cow-pox,  is  small-pox  aifecting  the 
cow,  or  is  a  different  disease  wliose  virus  is  protective  against 
small-pox,  is  not  yet  determined  to  the  satisfaction  of  all  investi- 
gators.^ Experiments  have  been  tried  repeatedly,  with  conflict- 
ing results.  Pasteur's  view  is,  that  vaccine  virus  is  merely  diluted 
virus  of  variola.  Either  way  the  fact  is  plain  that  most  persons 
are,  by  one  good  vaccination,  protected  for  life  ;  that  modified 
small-pox,  occurring  in  the  vaccinated,  is  very  seldom  indeed  fatal, 
and  hardly  ever  pits  ;  and  that  repeated  vaccination,  after  an 
interval  of  years,  will  make  protection  almost  always  complete. 
An  altogether  unjustified  distrust  of  vaccination  has  within  a  few 
years  done  harm  in  some  places. .  Besides  the  abundant  proof 
of  its  value  afforded  in  Jenner's  time  in  Europe,  recent  fjxcts 
confirm  the  opinion  that  small-pox  might  be  extirpated  by  its 
universal  use.  Dr.  Cameron  (Lectures  on  Health,  1868)  declares 
that  this  has  been  almost  entirely  effected  in  Ireland  ;  where,  on 
some  accounts,  we  might  expect  small-pox  to  abound.  In  Paris, 
1870,  an  alarm  about  "  vaccinal  syphilis  "  was  the  cause  of  a  very 
destructive  variolous  epidemic. 

Vaccination  may  be  performed  either  with  the  fresh  lymph,  the 
same  dried  by  keeping,  or  the  scab,  and  either  directly  from  the 
udder  of  the  cow,  or  from  a  human  being  inoculated  with  cow- 
pox.  In  Europe  the  lymph  of  the  vesicle,  before  maturation,  is 
generally  preferred,  In  this  country  the  scab  is  much  used,  and 
is  found  reliable  when  fresh  enough.  JSTo  matter  how  it  is  kept, 
after  a  month  it  is  uncertain  ;  although  it  has  sometimes  been 
found  efficient  after  being  sealed  up  for  a  year.^  When  kept  in 
hermetically  sealed  glass  tubes,  the  fresh  lymph,  dried  upon  frag- 
ments of  quill,  will  keep  nearly  as  long  as  the  scab.  Lymph  is  to 
be  obtained  on  the  eighth  or  ninth  day  after  the  vaccination  ;  by 
puncturing  the  sore  with  a  small  lancet  held  parallel  to  the  arm^  to 
avoid  drawing  blood.  Several  small  punctures  may  be  made. 
The  quill-pieces  do  best  to  be  nearly  a  quarter  of  an  inch  wide  at 
the  end,  and  sHghtly  roughened  by  scraping  with  a  knife,  to 
increase  absorption  of  the  lymph. 

Direct  inoculation  from  the  cow  often  makes  a  very  sore  arm, 
without  any  certain  increase  of  security.  The  cause  of  the  se- 
verity of  the  inflammation  appears  to  be,  usually,  some  impurity 
contaminating  the  virus.    Dr.  Loines,  upon  extensive  exjperience, 

iM.  Danet  of  Paris,  after  many  experiments,  pronounced  that  vaccinia  and  variola 
are  distinct  diseases.  (Med.  Times  and  Gazette,  Feb.  23, 1867.)  Jenner's  opinion  was 
that  they  are  the  same,  and  identical  also  with  the  grease  of  the  horse. 

2 Recent  observation,  authentically  reported,  seems  to  show  that  glycerin,  first 
suggested  by  Muller,  of  Berlin,  will  preserve  vaccine  virus  for  several  months.  The 
method  used  in  England  is,  to  take  matter  from  the  sore  on  the  eighth  day  of  the 
vaccination,  on  quill  points,  and  mix  it  with  ten  times  its  bulk  of  glycerin  diluted  with 
an  equal  quantity  of  water.  In  Germany  the  proportions  are,  lymph  one  part,  glycerin 
and  distilled  water  each  two  parts;  well  mixed  together. 


VACCINATION.  413 

declared  vaccination  from  the  heifer  to  be  less  certain  than  that 
from  arm  to  arm.  Dr.  Seatf)n,  author  of  an  excellent  work  on 
vaccination,  in  an  otTicial  report  testifies  against  animal  vaccina- 
tion as  a  substitute  for  tlie  human.'  I>r.  Ballard,  of  London, 
has  given-  statistics  showing  that  while  humanized  virus  aflbrda 
978  successes  for  1000  insertions,  the  best  results  with  animal 
virus  do  not  exceed  700  per  1000  insertions.  Dr.  II.  Stevens,  of 
the  English  Local  Government  Board,  who  has  probably  vacci- 
nated as  many  children  as  any  one,  declares  that  he  has  seen 
no  ground  for  the  opinion  that  humanized  lymph  has  lost  its  true 
and  original  Jennerian  character.  It  is  at  the  same  time  possi- 
ble that  many  transits  througli  hvmian  bodies  may  somewhat 
modify  the  virus.  Renewal  by  inoculating  healthy  children,  not 
too  young,  every  now  and  then,  from  the  udder  of  the  cow,  is  to 
be  recommended.  Cattle  with  the  cow-pox  may  be  found  in 
almost  any  agricultural  neighborhood.  As  Dr.  B.  Lee''  has  w^ell 
pointed  out,  the  most  reliable,  often  the  most  active  virus,  is  that 
which  has  been  recenthf  humanized;  especially  if  it  be  but  one  or 
a  few  removes  from  the  cow-pock. 

In  the  absence  of  small-pox  the  second  month  of  infancy  will  be 
time  enough  for  vaccination.  But  under  danger  of  exposure,  a 
babe  should  be  vaccinated  at  any  time  after  birth.  Matter  only 
from  healthy  children  ought  ever  to  be  used.  While  it  is  unlikely 
that  any  constitutional  disease  (as  syphilis'  or  scrofula)  will  be  so 
introduced,  there  should,  in  practice,  be  no  room  left  for  any 
doubt  of  the  kind  ;  and  some  cutaneous  diseases  might  certainly 
be  transmitted.  Unless  on  account  of  risk  from  exposure,  the 
existence  of  an  eruption  of  the  skin,  or  any  other  indisposition 
of  the  child  itself,  may  be  a  reason  for  postponing  the  operation. 
The  excitement  produced  by  it  may  aggravate  an  existing  inflam- 
matory affection.  Vaccination  has  often  been  blamed  for  the 
breaking  out  of  eruptions,  supposed  to  be  transmitted,  when  their 
cause  was  really  the  state  of  system  of  the  patient. 

For  the  operation,  the  outside  of  the  arm,  near  the  shoulder, 
is  commonly  selected.     The  exact  method  used  is  not  important. 
A  small  wedge-shaped  lancet,  or  even  a  sharp- 
pointed  penknife  will  do.     Various  slides  have  Fig.  119. 
been  contrived  for  the  purpose.    I  prefer  to  cut  ^ 
or  push  out  a  very  small  flap  of  the  cuticle,   ^; 
uncler  which  a  thick  paste,  made  by  pressing  ^; 
and  mixing  a  portion  of  the  scab  with  a  drop  ^^ 
of  tepid  water,  may  be  inserted.     Or,  instead 
of  the  scab,  a  lancet  charged  with  fresh  lymph  (arm  to  arm)  may 
be  employed.     Or,  to  use  the  quill  with  dried  lymph,  dip  it  for  a 

1  Twelfth  Report  of  the  Medical  Officer  of  the  Privy  Council,  Appendix  No.  7.  Lon- 
don, 1S70. 

2The  Practitioner.  February,  1S80. 

3  New  York  Med.  Journal,  May,  1872. 

*  At  Rivalta,  Italy,  and  Morbihan,  in  France,  and  in  England,  a  number  of  cases  of 
syphilitic  disease  (primary  and  secondary),  following  impure  vaccination,  have  been 
reported ;  the  best  instances  by  H.  Roger  and  DepauCand  by  Jonathan  Hutchinson  of 
London.  But  West,  Marson,  Seaton,  Loines,  and  others  assert  the  alarm  concerning  it 
to  be  groundless,  as  the  instances  of  it  are  excessively  rare,  and  ahcnys  preventable.  In 
North  Germany  (Auspitz,  Wiener  Med.  Wochenscrift,  Jan.  25,  1873X  only  one  or  two 
examples  of  it  occurred  in  twelve  million  vaccinations. 

35* 


414  ZYMOTIC    DISEASES. 

moment  in  tepid  water,  and  apply  it  to  the  abraded  or  incised 
part.  The  art  of  the  operation  is  to  pierce  the  skin  without 
drawing  enough  blood  to  flow.  Besides  the  flap  it  is  well  to 
scratch  the  skin  and  puncture  it  at  a  little  distance,  giving  three 
chances  of  taking  instead  of  one  ;  or  several  small  scratches  will 
do  (Fig.  119).  ]f  o  disturbance  of  the  arm  must  be  allowed  for 
twenty  minutes  or  half  an  hour  afterwards. 

If  it  be  successful,  no  sign  of  it  is  distinctly  visible  for  two  or 
three  days.  On  the  fourth  day  a  decided  small  red  pimple  is  to 
be  seen  and  felt.  This  becomes  a  vesicle  of  some  size  on  the  fifth 
day ;  it  grows  large  and  cylindrical,  or  hat-shaped,  and  by  the 
tenth  or"  eleventh  day  is  fully  umbilicated,  or  depressed  like  a 
navel  in  the  centre.  Before  that,  about  the  eighth  day,  the  bright 
red  ring  or  areola  forms  around  it.  This  fades  after  the  eleventh 
day,  and  the  vesicle  dries  up  into  a  round  and  flat,  but  rather 
thick,  mahogany-colored  scab,  which  falls  off  about  the  nine- 
teenth day.  All  of  these  particulars  are  important,  as  showing 
the  genuineness  of  the  vaccination.  So  is  the  appearance  of  the 
cicatrix  left ;  which  should  be  large  in  proportion  to  the  vesicle, 
and  dotted  or  marked  with  subdivisions.  This  is  owing  to  the 
vesicle  being  composed  of  several  small  cells  or  compartments. 

Slight  fever,  with  restlessness,  is  not  unfrequently  observed 
dm'ing  the  first  few  days  after  the  vesicle  appears ;  but  there  is 
rarely  anything  requiring  treatment. 

Re-vaccination. — Experience  shows  that  a  number  of  persons, 
after  several  years,  reacquire  the  susceptibility  to  small-pox. 

As  the  only  test  of  tliis  is  exposure  either  to  the  latter  or 
vaccinia,  the  renewal  of  this,  at  least  once  after  puberty,  is  always 
advisable.  On  the  occasion  of  epidemic  small-pox  it  may  be 
repeated  again  and  again.  There  is  no  pain  of  any  consequence 
in  the  operation,  nor  danger,  and  if  a  genuine  vesicle  form, 
making  a  sore  arm,  that  discomfort  for  a  few  days  cheaply  pur- 
chases immunity  from  the  terrible  disease,  I  have  sometimes 
thought  it  possible  that  the  system  may  be  protectively  affected 
by  re-vaccination,  even  when  no  local  effect  or  only  a  "  spurious  " 
sore  follows.  Certainly  small-pox  is  extremely  rare  in  re-vac- 
cinated persons,^  M.  Danet,  in  an  official  report,  insists  that 
persons  who  have  had  small-pox  should  also  be  re-vaccinated. 

The  virus  from  a  second  vaccination  should  not  be  relied  upon 
for  use. 

VAKICELLA. 

Synonym. — (Jliicken-X)OX.  This  is  a  mild  exanthematous  disease 
resembling  small-pox  or  varioloid  considerably.  Hebra,  of  Vienna, 
asserted  its  identity  with  variola ;  but  this  opinion  is  not  well 
sustained  by  facts.  After  an  incubation  of  four  or  five  days  from 
exposure  to  the  contagion  of  one  having  it,  pimples  form,  gen- 
erally scattered  widely.     In  the  second  day  they  become  vesicles 

1  According  to  testimony  obtained  by  a  Medical  Conference  upon  the  subject  of  vac- 
cination at  Paris,  in  1870,  the  proportion  of  the  re-vaccinated  liable  to  variolous  infec- 
tion is  2.33  per  cent.  Prof  Corfield,  of  London,  has  stated  (Nature,  Oct.  16,  1873),  that, 
of  fifteen  thousand  cases  of  small-pox  in  the  London  hospitals  during  the  last  epidemic, 
only  four  presented  j)roof  of  having  been  re-vaccinated.  In  1880  (Buchanan)  the 
death-rate  per  million  in  London  from  small-pox  was  90  among  the  vaccinated  against 
3350  among  the  unvacciaated. 


SCARLATINA.  415 

filled  "with  lymph.  Two  or  tlircjo  days  more  find  them  scabbing ; 
they  dry  and  lall  off  soon,  witjiout  pitting,  except  in  rare  instances. 
There  is  little  or  no  fever  or  other  indisposition.  The  disease  is 
attended  with  no  danger  to  life,  and  requires  only  precautionary 
treatment,  i.  c,  to  avoid  exposure  to  cold  and  wet,  to  keep  the 
bowels  regular,  and,  if  needful,  promote  action  of  the  skin  by  a 
diaphoretic,  as  neutral  mixture  or  hq.  ammou.  acetat. 

The  eruption  of  varicella  differs  from  that  of  variola  in  coming 
out  in  successiv^e  crops;  in  not  suppurating  or  becoming  umbil- 
icatcd ;  and  in  not  deeply  involving  the  true  skin.  Inoculation 
has  been  found  to  foil  in  propagating  it,  and  vaccination  has  no 
preventive  power  over  it.  Adults  are  very  seldom  affected  with 
it,  and  it  is  more  often  epidemic  than  small-pox. 

SCARLATINA. 

Synonym. — Scarlet  fever. 

"Varieties. — Scarlatina  simplex,  anginosa,  and  maligna. 

Symptoms  and  Course. — After  an  incubation  usually  of  about 
five  days  from  exposure  to  its  cause,  lassitude,  anorexia,  head- 
ache, pains  in  the  back  and  limbs,  mark  the  beginning  of  the 
attack.  Soon  these  are  followed  by  fever  ;  on  the  first  day,  very 
often,  the  throat  is  sore.  On  the  second  day,  usually,  a  punc- 
tated red  eruption  appears  on  the  face  and  neck,  and  in  ten  or 
twelve  hours  has  covered  the  whole  body.  It  is  of  a  scarlet  or, 
sometimes,  a  brick-red  hue,  uniformly  diffused,  with  a  swollen 
appearance  and  great  heat,  reaching  by  the  thermometer  lOo'^ 
or  106°  Fahr.  Occasionally  miliary  vesicles  are  seen.  There  is 
also  a  sense  of  burning  and  some  soreness  or  irritation  of  the 
skin.  The  tongue  has  a  strawberry-like  look,  from  the  projec- 
tion of  enlarged  red  papillce  through  a  whitish  fur.  The  throat 
is  very  red  and  swollen,  generally,  with  a  hue  not  unlike  that  of 
the  skin.  Fever  runs  very  high,  with  an  extremely  rapid  pulse, 
great  thirst,  headache,  perhaps  delirium,  costiveness,  in  some 
cases  vomiting.  Bad  cases  may  have  stupor.  By  the  fifth  day, 
mild  examples  of  the  disease  show  already  an  abatement.  Most 
have  passed  the  height  of  the  pyrexia  by  the  ninth ;  although 
sequelce  may  protract  the  attack  much  longer.  Malignant  cases* 
may  be  fatal  in  a  day  or  two,  or  even  in  less  than  twenty-four 
hours.  Desquamation  of  the  skin  follows  the  fading  of  the  erup- 
tion, often  large  masses  of  cuticle  coming  away  at  once.  At  this 
stage  more  or  less  decided  albuminuria  is  common. 

Scarlatina  Simplex. — In  this  the  eruption  comes  out  early 
and  well,  with  moderate  fever,  little  or  moderate  inflammation 
of  the  throat,  and  an  even  course  throughout.  Sometimes  there 
is  hardly  any  febrile  disturbance  ;  the  child  may  even  play  about 
without  having  to  go  to  bed. 

Scarlatina  Anginosa. — Here  the  violence  of  the  disease  falls 
upon  the  throat  chiefly.  The  tonsils  swell  greatly,  suppurating 
either  early  or  late,  or  they  are  covered  by  pseudo-membranous 
deposit,  white,  gray,  or  dark-brown,  whose  coming  away  leaves 
an  ulcerous  surface,  with  in  some  instances  an  acrid,  offensive 
discharge.     The  extension  of  the  ulcerative  inflammation  may 


416  ZYMOTIC    DISEASES. 

I)ass  the  Eustachian  tube  to  the  tympanum,  and  may  destroy 
the  auditory  apparatus  so  as  to  cause  permanent  deafness. 
After  the  rash  has  disappeared,  abscesses  in  the  neck  may  form 
and  discharge,  exhausting  the  patient. 

Scarlatina  Maligna. — This  term  designates  an  overwhelming 
toxeemic  impression  of  the  morbid  cause  of  the  disease.  Depres- 
sion in  the  first  stage  becomes  intense,  without  reaction  ;  or,  after 
the  eruption  has  partly  come  out,  it  recedes,  or  grows  livid  in 
appearance  ;  or  the  brain  is  oppressed  with  coma.  Coldness  is 
sometimes  present,  or  unequal  temperature  of  different  parts  of 
the  body,  instead  of  the  usually  diffused  febrile  heat.  The  throat 
may  be  much  or  little  affected.  In  some  instances  the  patient 
seems  almost  as  if  struck  by  lightning,  so  sudden  and  deep  is  the 
general  prostration.  In  this  condition  death  may  take  place  in 
a  few  hours.  Otherwise,  there  is  continued  prostration,  and 
hemorrhage  from  the  stomach  or  bowels,  or  vomiting,  or  diar- 
rhoea threatens  an  untoward  result. 

Sequelae. — Abscesses  about  the  throat  have  been  mentioned  ; 
similar  local  affections  may  take  place  elsewhere  after  the  attack. 
Ozsena  is  not  uncommon  ;  neither  is  suppurative  inflammation 
of  one  or  more  of  the  joints,  or  of  the  testicle  ;  nor  vaginitis. 
Endocarditis  or  pericarditis  may  occur.  So  may  paralysis ; 
either  hemiplegia  or  paraplegia  ;  generally  this  is  partial,  and  it 
is  often  slowly  recovered  from. 

Dropsy  from  arrested  action  of  the  kidneys,  with  imperfect 
action  of  the  skin,  is  the  most  common,  and  in  many  cases  the 
most  serious  of  the  sequelae  of  scarlatina.  It  comes  most  fre- 
quently within  a  week  or  two  after  desquamation  has  commenced. 
Mild  cases  are  almost  as  likely  to  be  followed  by  it  as  severe  ones. 
Exposure  to  cold  is  the  generally  observable  direct  cause  ;  but 
cases  happen  in  which  no  such  exposui'e  could  have  existed. 
Wagner,  Biermer,  Klein,  and  Putnani-Jacobi^  have  found  post- 
mortem proof  of  interstitial  nephritis  in  several  instances.  Ana- 
sarca is  the  least  dangerous  though  most  frequent  form  of  this 
dropsy.  There  may,  instead  or  in  addition,  be  ascites,  hydro- 
thorax,  or  hydrocephalus.  Albuminuria,  and  often  hsematuria, 
may  accompany  either  form. 

Diagnosis. — From  measles,  scarlet  fever  is  known  by  the  erup- 
tion coming  out  on  the  second  day,  without  catarrhal  symptoms, 
but  with  sore  throat,  and  by  its  being  of  a  brighter  red  color, 
and  uniformly  diffused  instead  of  being  in  patches. 

Erom  roseola,  it  is  distinguished  by  the  fever  and  sore  throat, 
and  by  the  rash  in  the  latter  being  in  irregular  blotches,  and  of  a 
damask  rose  color  instead  of  a  brick-  or  scarlet-red  hue. 

Prognosis. — This  is  proverbially  uncertain  in  scarlet  fever. 
The  simple  form  is,  however,  the  least  dangerous,  and  a  very 
large  majority  of  cases  get  well.  The  anginose  is  more  threat- 
ening and  serious.  But  the  malignant  variety,  as  its  name  indi- 
cates, is  far  the  most  so;  recovery  from  it  is  the  exception, 
although  it  does  occur.  I  have  known  two  cases  of  such  recov- 
ery, one   in  which   coma  was   complete   for  thirty-six  hours. 

1  N.  y  Med.  Record,  March  26, 1881,  pp.  353-5, 


SCARr.ATINA.  417 

Adults  are,  when  afiected  with  scarlet  fever,  in  somewhat  greater 
danger  than  children,  and  sa,  especially,  are  puerperal  women. 

Causation. — Although  most  (not  all)  authorities  agree  that  this 
disease  is  contagious,  it  is  certainly  very  capricious  or  variable 
in  its  manifestation  of  this  quality.  That  is,  many  persons  who 
are  exposed  escape  it.  It  is  true  that  several  children  in  a  family 
often  have  it  in  immediate  succession.  But  the  escape  of  all  but 
one  is,  so  far  as  my  observation  has  gone,  as  common.  It  rarely 
occurs  twice  in  the  same  person.  I  remember  but  one  or  two 
instances  of  this  in  my  own  practice.  It  seldom  occurs  in  infants 
under  three  months  of  age. 

Treatment. — Mild  cases  require  no  medication  at  all,  other 
than  to  make  sure  that  the  bowels  are  well  opened.  If  fever  is 
high,  after  a  saline  cathartic  (citrate  or  sulphate  of  magnesium 
or  Rochelle  salts),  neutral  mixture  or  eft'ervescing  draught,  or 
liquor  of  acetate  of  ammonium  may  be  given.  Sweet  spirits 
of  nitre  may  be  added,  in  small  doses  (}  to  o  fluidrachm  for  an 
adult,  and  proportionately  less  for  a  child)  if  the  kidneys  act 
slowly.  Drinking  cold  water  freely  is  to  be  encouraged,  as  it  is 
demanded  by  thirst.  If  the  throat  be  much  inflamed,  the  fre- 
quent melting  in  the  mouth  of  ice,  in  small  pieces,  will  do  good. 

Dr.  Egbert:,  of  Pennsylvania,^  uses,  instead,  an  ice-bay^  applied 
to  the  throat.  This  must  require  caution,  not  to  allow  the  local 
impression  of  cold  to  become  extreme. 

Venesection  is  prohibited  now  in  scarlatina  by  nearly  all  writers. 
In  the  earl}^  part  of  my  practice,  I  bled  from  the  arm  in  six  cases, 
all  of  which  did  remarkably  well.  They  were  examples  of  violent 
fever  with  abundant  eruption,  severe  sore  throat  and  headache, 
in  children  of  good  constitution.  I  do  not  advocate  the  practice, 
simply  in  deference  to  the  common  opinion  of  the  profession. 
Certainly  it  should  be  always  ruled  out  in  asthenic  cases,  and  in 
all  unless  at  the  early  stage  of  the  fever.  Di-.  Squire  and  others 
have  reported  well  of  the  employment  of  quinine,  in  5  or  10  grain 
doses,  during  the  height  of  the  febrile  attack  in  scarlatina. 

For  the  sore  throat,  which  is  specific  in  character,  besides  the 
use  of  leeches  externally,  if  the  inflammation  be  great  and  the 
case  sthenic,  local  alteratives  may  be  used.  An  old  and  popular 
gargle  is  one  of  red  pepper,  vinegar,  and  water.  More  powei'ful 
in  changing  the  character  of  the  inflammation,  I  think,  is  a  strong 
solution  of" nitrate  of  silver  (gr.  xxx  in  f,3J)  applied  with  a  large 
hair  pencil.  When  pseudo-membranous  patches  appear,  with  a 
tendency  to  fetor  or  ulceration,'-'  muriatic  acid,  with  honey,  equal 
parts,  may  be  applied  in  a  similiar  way ;  or,  diluted,  used  as  a 
gargle.  Sulphate  of  zinc  (gr.  xv  to  xx  in  fgj)  is  also  a  good 
application ;  and  so  are  solutions  of  creasote  in  glycerin  ;  of 
chlorinated  soda  ;  and  of  permanganate  of  potassium. 

For  the  irritation  of  the  skin  connected  with  the  rash,  according 
to  my  experience  the  best  relief  is  to  be  obtained  by  sponging 
"with  cool  or  tepid  water,  two  or  three  times  a  day.     Inunction 


1  Transactions  of  Penna.  Med.  Society,  1872. 

2  Sir  W.  Jenner  considers  the  danger  to  be  increased  by  septic  infection  from  absorp- 
tion of  fetid  material  from  the  ulcerated  throat. 

2B 


418  ZYMOTIC    DISEASES. 

with  lard,  or  glycerin,  is  preferred  by  some.  Cold  affusion  is 
unnecessarily  violent  and  troublesome. 

The  diet  in  scarlet  fever  should  be,  as  a  rule,  liquid,  but  need 
not  be  low,  generally,  in  the  sense  of  dilution  or  exclusion  of 
animal  material,  unless  in  the  first  few  days.  Sooner  than  in 
most  diseases,  the  tendency  to  debility  is  manifest.  Then,  milk, 
chicken-broth,  mutton-tea  or  beef-tea,  etc.,  will  be  suitable.  At 
the  same  stage,  some  patients  will  require  a  tonic  treatment,  by 
quinine,  or,  as  some  prefer,  nitric  acid  in  small  doses. 

Ilalignant  scarlatina  is  a  disease  of  terrible  depression  from  the 
outset.  Deficiency  of  reaction  is  one  of  its  characteristics.  To 
promote  this,  external  stimulation  is  primarily  important.  The 
hot  salt  or  mustard  bath  is  a  powerful  agent  for  the  purpose. 
Urtication,  i.  e.,  the  direct  application  of  fresh  nettles,  has  been 
sometimes  employed.  Mustard  plasters  may  be  applied  energet- 
ically ;  and  so  may  hot  bottles,  or  bags  of  hot  salt,  etc.  Inter- 
nally, ammonia,  quinine,  and  cajisicura  are  the  most  prompt  and 
reliable  stimulants,  although  we  may  add  to  the  same  list, 
Hoffmann's  anodyne,  and  brandy,  whisky,  or  wine.  Where  a 
tendency  to  stupor  exists  free  purging  will  be  the  main  hope. 
Jalap  is  a  convenient  article  for  the  purpose  [F.  151] . 

The  sulphite  of  sodium  is  still  under  trial  in  various  zymotic 
diseases,  as  an  antagonistic  of  morbid  blood-changes.  The  dose 
for  an  adult  may  be  about  ten  grains  every  two  or  three  hours 
[F.  152].  Chlorine  water,  in  fluidrachm  doses  for  an  adult  (ten 
drops  for  a  child  of  two  years),  is  sometimes  given  in  scarlet  fever 
with  a  similar  view ;  and  so  is  chlorate  of  potassium.^ 

Other  modes  of  treatment  for  severe  cases  are,  the  use  of 
tincture  of  chloride  of  iron  freely  ;  of  infusion  of  digitalis  (L.  P. 
Gebhard) ;  of  diluted  acetic  acid  (5j  to  5iv  of  the  officinal  acid 
in  fgiv  of  water,  the  dose  of  the  solution  being  a  tablespoonful, 
sweetened,  every  few  hours)  ;  of  bromide  of  sodium ;  and  of 
diluted  nitric  acid.  Carbolic  acid,  in  one-  or  two-grain  doses, 
diluted,  has  been  used  by  Drs.  Kempster,  Bissell,  Fuller,  Shoe- 
maker, and  Cleaver,  with  asserted  beneficial  efieets.^  Its  dose' 
should  be  always  small  (1  grain),  and  given  well  diluted  with 
water.  Dr.  E.  Martin  {Lancet,  Jan.  8,  1876)  has  suggested  the 
use  of  medicated  ice,  when  children  resist  local  applications  to  the 
throat ;  as  very  often  happens.  A  large  test-tube  may  be  nearly 
filled  with  the  required  solution,  and  then  immersed  in  a  mixture 
of  pounded  ice  and  salt.  When  it  is  frozen,  a  momentary  dip  of 
the  tube  in  hot  water  will  enable  the  cylinder  to  be  turned  out ; 
it  can  then  be  given  to  the  child  as  ice. 

Of  the  sequelae  of  scarlet  fever,  each  has  its  own  indications  for 
treatment.     That  of  dropsy  is  the  most  frequently  important. 

iSee  Squire,  on  Te.mperaturo  Variations  in  Children,  1871. 

deleaver,  in  Iowa  Med.  Journal,  1869.  Dr.  Kempster,  of  Utica,  and  Dr.  A.  M.  Car- 
penter (Physician  and  Pliarmaeeutist,  November,  1868),  use  carbolic  acid,  with  glycerin 
and  water,  as  a  local  remedy  for  the  sore  throat  of  scarlatina. 

3  Read  win  (Pharmaceutical  Journal,  Oct.,  1869),  gives  the  following  quantities  as  safe: 
for  internal  use,  1  grain  of  pure  carbolic  acid  (crystals)  in  a  fluidounce  of  water.  _  As 
a  gargle,  1  or  2  grains  in  an  ounce  of  water.  For  injection,  1  grain  to  4  ounces ;  lotion, 
15  grains  to  an  ounce  of  water;  liniment,  1  part  to  20  of  olive  oil ;  ointment,  16  grains 
to  an  ounce  of  lard.  Some  facts  of  experience,  accidental  and  therapeutic,  render  it 
not  improbable  that  carbolic  acid  may  be  safe  iu  larger  than  one-grain  doses. 


MEASLES.  419 

If,  (luring  desquamation,  tlie  kidneys  show  any  threatening;  of 
suppression  or  inaction,  the  greatest  care  of  the  state  of  the  skin 
must  be  maintained.  It  is,  indeed,  a  good  rule  of  precaution, 
for  fear  of  some  carelessness  and  exposure,  not  to  allow  a  patient 
recovering  from  scarlet  fever  to  leave  his  chamber  for  three  or 
four  weeks  at  least,  from  the  beginning  of  the  attack,  nor  the 
house  for  four  or  five  weeks.  Lemonade  as  a  drink,  if  the  urine 
be  scanty,  may  be  freely  used.  Cream  of  tartar  and  acetate  of 
potassium  are  approved  in  the  same  case  as  diuretics.  Digitalis 
has  tlie  contidence  of  many.  Quinine,  in  doses  large  enough  to 
cinchonize,  is  reported  very  favorably  of,  in  scarlatinal  dropsy, 
by  some  practitioners.  Pilocarpin  may  act  powerfully,  through 
the  skin,  but  requires  much  care,  for  fear  of  depression.  Dry 
cupping  to  the  lumbar  region,  and  the  application  there  of  a 
large  mustard  plaster,  are  measures  suggested  by  the  known 
congested  state  of  the  kidneys.  Dr.  C.  West  even  bleeds  from 
the  arm  upon  the  same  indication  ;  a  practice  which  I  should 
hesitate  to  follow,  after  so  exhausting  a  disease  as  scarlet  fever. 
Pui-gatives  must  not  be  omitted  when-  diuretics  fail ;  the  princi- 
ples governing  their  use  being  the  same  as  in  other  varieties  of 
dropsy. 

Prophylaxis. — Belladonna  has  been  asserted  to  have  a  protec- 
tive power  against  the  contagion  or  infection  of  scarlet  fever. 
But  the  evidence  in  its  favor  does  not  appear  to  me  to  warrant 
our  giving  any  contidence  to  it,  or  to  any  prophylactic. 

MEASLES. 

Sjnonym.—MorbilU.  Formerly,  with  all  writers,  and  still  with 
many,  rubeola  is  a  synonym  for  measles.  Some  writers,  however, 
designate  by  the  name  of  rubeola  only  a  hybrid  or  blending  of 
measles  with  scarlatina.     (See  Botheln.) 

Symptoms  and  Course. — After  an  incubation  of  from  ten  to 
fifteen  days  from  exposure  to  its  contagion,  the  attack  begins 
with  a  slight  or  obscure  stage  of  depression,  passing  into  fever. 
With  this  there  are  all  the  symptoms  of  a  cold ;  running  at  the 
nose,  redness  and  watering  of  the  eyes,  and  a  cough.  On  the 
fourth  day  of  the  attack  the  rash  begins  on  the  face,  and  extends 
over  the  body  and  limbs.  It  is  not  so  bright  in  color  as  the  erup- 
tion of  scarlet  fever ;  and  is  irregularly  distributed  in  patches 
more  or  less  crescentic  in  shape.  By  about  the  seventh  day  the 
rash  begins  to  fade,  and  about  the  same  time  or  before,  the  fever 
has  begun  to  decline.  Desquamation  is  much  less  extensive  than 
after  scarlatina. 

No  such  intensity  of  febrile  movement,  nor  severity  of  any 
kind,  as  is  common  in  the  last-named  disease,  exists,  except  very 
rarely,  in  measles.  Camp  measles,  during  the  late  war  in  this 
country,  sometimes  assumed  a  typhous  character,  with  a  consid- 
erable mortality  ;  due  to  the  conditions  under  which  it  occurred 
among  the  soldiers. 

Savages  have  sometimes  suffered  much  from  it ;  as  in  the  Fiji 
Islands  in  1875,  when  from  one-fourth  to  one-fifth  of  the  popula- 
tion died  of  it.    Under  ordinary  circumstances,  unless  in  very 


420  ZYMOTIC    DISEASES. 

young  children,  measles  seldom  threatens  life.  Even  in  so  devel- 
oped a  country  as  Japan,  however,  as  reported  by  Dr.  D.  B.  Sim- 
mons, in  1861,  75,000  deaths  occurred  from  it. 

Occasionally,  the  bronchitis  may  become  capillary,  or  may  be 
extended  into  broncho-pneumonia.  Much  less  often,  gastro-intes- 
tinal  inflammation,  with  vomiting,  abdominal  pain,  and  dysenteric 
diarrhoea,  may  complicate  the  attack.  Of  314  cases  observed  by 
Meigs  and  Pepper,  7  were  thus  affected  ;  but  all  of  these  recov- 
ered. Others  have  reported  a  few  deaths  resulting  from  this 
complication. 

The  possible  sequelae  which  are  of  the  most  consequence  are, 
ophthalmia,  diphtheria,  chronic  bronchitis,  and  phthisis.  Yery 
severe  inflammation  of  the  eyes  sometimes  follows  measles ;  but 
blindness  from  this  cause  is  rare.  Diphtheritic  sore  throat  is  not 
infrequent,  and  may  be  fatal  in  children.  Chronic  bronchitis  is 
common,  especially  when  care  is  not  taken  during  convalescence 
to  avoid  exposure.  Phthisis,  under  the  same  circumstances,  is 
to  be  apprehended  only  where  the  constitution  suffers  under  a 
predisposition  to  tuberculaT  disease. 

Causation. — ^Measles  is  one  of  the  most  contagious  of  diseases, 
beyond  all  doubt.  Singularly  enough,  however,  I  once  attended 
w^ith  it  one  of  a  pair  of  twins  at  the  same  mother's  breast,  the 
other  escaping  it  altogether.  A  second  attack  is  exceptional,  but 
not  very  rare.^ 

Treatment. — Beginning  with  a  moderately  active  saline  cathar- 
tic, diaphoretics,  expectorants,  and  demulcents  are  next  in  place. 
On  account  of  the  possibility  of  diarrhoea,  it  is  well  to  be  careful 
with  the  use  of  strong  purgative  medicines  in  measles.  Yet,  on 
the  other  hand,  the  necessity  of  sufficient  elimmation  of  excretions 
must  be  borne  in  mind.  It  is  decidedly  better,  during  the  first 
few  days,  for  the  bowels  to  be  freely  moved  than  confined ;  and, 
in  checking  excessive  discharges,  it  should  be  remembered  that 
accumulation  of  effete  material  in  the  blood  renders  the  action 
of  opiates  more  narcotic,  and,  in  large  doses,  even  dangerous. 
Syrup  of  ipecacuanha  with  neutral  mixture  (J  drachm  of  the 
former,  for  an  adult,  with  each  tablespoonful  of  the  latter)  every 
two,  three,  or  four  hours,  would  be  an  average  treatment  for  the 
first  week ;  flaxseed  lemonade  being  freely  used  as  a  drink.  After 
that,  the  continuance  or  relief  of  the  bronchial  symptoms  must 
determine  whether  some  other  expectorant  (as  squills  or  wild 
cherry)  shall  follow.  Debility  may  require  tonics  during  con- 
valescence. 

ROTHELN :— HYBEID  BETWEEN  SCARLATINA  AND  MEASLES. 

Synonym. — German  Measles. 

This,  called  Buheola  by  some,  is  not  common,  but  is  less  rare  now 
than  formerly.     I  have  seen  a  case  in  which  the  symptoms  of  the 

1  Not  long  since,  Dr.  Salisbury,  of  Ohio,  produced  measles-like  symptoms  in  several 
persons  by  exposing  them  to  the  influence  of  fungi  growing  upon  damp  straw.  The 
identity  of  the  affection  with  measles  was  not,  however,  shown.  Drs.  Hammond  and 
Woodward,  at  Washington,  repeated  the  same  experiments  without  result.  Some  Brit- 
ish writers  aver  that  rubeola  notha  is  a  distinct  disease,  and  may  be  ascribed  to  straw- 
fungus. 


ROTIIELN.  421 

two  disorders  were  so  nicely  balanced  that  two  physician?  of 
similar  experience  pBonoui>ced  it,  the  one  scarlet  fever,  and  the 
other  measles.  Dr.  MaL,a-uder,  of  Olney,  Maryland,  has  reported 
a  case  in  which  tlie  two  kinds  of  eruption  coexisted  on  dillerent 
parts  of  the  body  of  the  same  patient.'  Dr.  Murchison  and 
others  assert  "German  measles"  to  be  an  entirely  distinct  dis- 
ease, an  attack  of  wliich  afibrds  no  immunity  from  either  measles 
or  scarlet  fever.'-  If  this  be  so,  such  a  disease  has  been  in  former 
3'ears  little  known  in  this  country.  Dr.  J.  Lewis  Smith,  in  the 
Sanitarian  for  July,  1874,  gave  a  ])rief  account  of  its  prevalence 
as  an  epidemic  in  New  Yoi"k  at  that  date. 

In  IST."),  thirti!en  cases  of  it  occurred  at  Haverford  College, 
near  Philadelphia.  In  these  cases,  the  early  general  symptoms 
were  mild  ;  malaise,  headache,  slight  sore  throat,  loss  of  appetite, 
and  debility.  In  two  or  three  days,  with  some  increase  of  fever, 
a  rash  appeared,  having  more  the  color  of  scarlet  fever  than  that 
of  measles,  but  dotted  or  miUary  (sub-papular  j  in  form.  In  some 
cases  it  became  aluicst  couLiiiuous,  with  a  moderate  amount  of 
tumefaction  of  the  limbs  and  general  surface.  In  one  instance 
the  fauces  exhibited  a  scarlet  hue  to  the  eye,  although  no  feel- 
ing of  soreness  of  the  throat  existed  in  that  case.  Catarrhal 
symptoms  were  not  noticed  in  any  of  these  patients.  In  some 
of  them,  the  glands  of  the  neck  were  swollen.  None  had  a  very 
high  fever.  The  duration  of  the  attack  in  each  case  was  about 
a  week ;  and  convalescence  was  rapid.  No  sequeliB  were  observed 
in  any  instance. 

During  the  summer  of  1878  I  saw  three  cases  of  rotheln  with 
Dr.  Macomber  in  Germantown,  Pa.  They  closely  resembled 
those  above  described.  An  interesting  feature  concerning  them 
was,  that  they  occurred  in  a  period  of  transition  between  a  con- 
siderable epidemic  of  scarlet  fever  and  the  most  extensive  x^rev- 
alence  of  measles  ever  known  in  the  locality.  In  1880-81,  many 
cases  of  riitheln  or  rubeola  (often  inaccurately  called  roseola)  were 
recognized  by  practitioners  in  Philadelphia.*  Dr.  I.  Minis  Hays'* 
observed  the  occurrence  of  this  affection  (in  an  institution)  in 
fifteen  persons  who,  within  a  year,  had  been  the  subjects  of  ordi- 
nary measles.  Dr.  Forrest,^  of  Charleston,  S.  C,  mentions  the 
occurrence  of  a  widespread  epidemic  of  German  measles  in  that 
city  during  the  first  four  months  of  the  year  1880.  In  the  winter 
of  1880-81,  there  was  a  considerable  prevalence  of  it  in  the  city 
of  New  York ;  and  a  number  of  cases  in  Chicago.  Dr.  D.  B. 
Simmons,  of  Yokohama,  asserts  that  rotheln  or  "rubeola  Ger- 
manica"  is  quite  common,  as  a  mild  epidemic,  in  Japan. 

In  severity,  the  hybrid  attack  is  generally  more  like  measles ; 
although  dropsy  and  albuminuria  may  follow  it,  as  well  as  bron- 
chitis, etc.  Its  treatment  requires  no  special  consideration, 
being  involved  in  what  has  been  said  of  the  two  diseases  of 
which  it  really  seems  to  be  a  combination. 

1  Med.  and  Surg.  Reporter,  July  16,  1881,  p.  81. 

2  See  a  Lecture  by  Dr.  Liveinjj,  March  14,  1874. 

3  See  a  paper  by  Dr.  L.  A.  Duliring,  March  26, 1881.  *  Ibid. 
6  Amer.  Journal  of  Med.  Sciences,  April,  1881. 

36 


422  ZYMOTIC    DISEASES. 

MUMPS, 

Synonjrms. — Parotitis  contagiosa;  Cynaiwhe  parotidea. 

Symptoms  and  Course. — This  is  generally  a  mild  affection,  of 
a  few  days'  duration.  The  parotid  gland  swells  and  becomes  hot, 
painful,  and  tender  to  the  touch.  Some  inconvenience  in  swal- 
lowing may  result.  There  is  little  or  no  fever,  but  some  general 
malaise ;  and  the  attack  is  generally  at  an  end  within  a  week. 
Once  in  awhile  an  attack  may  be  quite  severe  ;  with  high  fever, 
delirium,  etc.  One  or  both  parotids  may  be  affected.  There 
seems  to  be  reason  to  believe  that  attacks  may  occur  at  con- 
siderable intervals,  even  of  j^ears,  involving  first  one  gland  and 
afterwards  the  other.  Suppuration  is  rare ;  I  have  seen  it  but 
in  one  case.     The  disease  is  undoubtedly  contagious. 

Bouchut,  in  1873,  in  a  communication  to  the  French  Acad- 
emy, brought  forward  the  remarkable  assertion  that  parotitis  is 
simply  a  salivary  retention,  due  to  catarrhal  inflammation  of  the 
parotid  duct. 

Diagnosis. — As  the  parotid  gland,  as  well  as  other  glands 
about  the  neck,  may  inflame  from  cold,  septicsemia,  or  scrofula,  it 
becomes  sometimes  a  question  whether  a  swelling  in  that  region 
be  mumps  or  not.  When  the  parotid  alone  is  affected,  it  is 
impossible  to  decide,  unless  direct  exposure  to  another  case  of 
mumps  be  known.  The  parotid  is,  however,  not  apt  to  inflame 
under  other  causation,  even  from  salivation  by  mercury,  the 
submaxillary  glands  are  much  more  liable  to  swell  from  that 
cause.  The  suddenness  of  the  attack,  and  its  brief  duration, 
are  generally  quite  diagnostic  of  mumps,  as  compared  with  scrof- 
ulous or  other  inflammations  of  glands  about  the  neck. 

Complications. — Metastasis  of  mumps,  to  the  mamma  or  tes- 
ticle, or  even  to  the  brain,  occasionally  occurs.  Instances  of  the 
last-named  complication  have  come  to  my  knowledge.  In  either 
of  the  first  two,  a  somewhat  similar  inflammation  of  the  gland 
attacked  takes  place ;  usually  more  protracted  than  that  of  the 
parotid.  If  the  brain  be  the  seat  of  the  transfer  of  the  morbid 
element  or  action,  meningitis,  or  coma,  may  follow ;  and  even 
death  is  said  thus  to  have  resulted.  Otherwise,  mumps  is  free 
from  danger  to  life. 

Treatment. — Care  to  avoid  being  chilled,  lest  metastasis  or 
greater  severity  of  the  attack  be  produced,  is  important.  No 
general  treatment  is  necessary,  nor  does  the  patient  usually  need 
to  remain  in  bed.  Perhaps  a  mild  laxative  may  be  given  on  the 
first  or  second  day.  A  poultice  of  flaxseed  meal  is  a  good  local 
application  for  the  gland.  It  may  also  be  bathed  night  and 
morning  with  soap  or  volatile  liniment. 

HOOPING-COUGH. 

Synonjrm. — Pertussis. 

Symptoms  and  Course.— After  an  incubation  of  about  six  days, 
the  attack  commences  with  symptoms  much  like  those  of  acute 
bronchitis,  including  fever  of  variable  degree  ;  soon  showing  its 
peculiar  character.  This  is,  a  spasmodic  and  paroxysmal  cough. 
For  hours  the  patient  may  be  apparently  well,  and  then,  often 


H  O  O  P  I  N  O  -  C  O  U  O  H  .  423 

with  a  premonitory  sensation  which  leads  the  child  to  run  to  its 
mother  or  nurse,  or,  if  at  night,  to  sit  up  in  bed,  a  fit  of  coughing 
begins,  and  lasts  for  several  seconds  or  minutes.  It  consists  of  a 
rapid  succession  of  sliort  but  violent  expiratory  efforts,  witli 
scarcely  any  intervals  of  inspiration  ;  at  the  close  of  which,  air  is 
taken  in  by  force  tlirough  tlie  contracted  glottis,  making  a  whoop- 
ing sound,  whence  tlie  name  of  tlie  disease.  All  who  have  it  do 
not  whoop  ;  but  the  paroxysmal  character  of  the  cough  is  pathog- 
nomonic. 

Expectoration  is  copious,  of  thick  mucus,  sometimes  even  of 
lymph  and  pus.  Vomiting  occurs  often  during  the  spells  of 
coughing.  The  child  may  become  very  much  exhausted,  even  to 
a  fatal  end  ;  but  unless  from  complication  or  previously  feeble 
constitution,  death  does  not  very  often  occur.  I  never  knew 
asphyxia  to  be  fatal  during  the  paroxysm,  though  it  is  sometimes 
threatening.  One  case  has  come  to  my  knowledge  in  which  death 
took  place  with  apoplectic  symptoms.  Intense  congestion  of  the 
eyes,  from  the  violent  coughing,  is  common.  There  may  be  many 
variations  of  severity  in  all  the  symptoms  in  the  course  of  an 
attack.  Dr.  Gibb  has  found  the  urine  saccharine  in  this  disease. 
Ulceration  under  the  tongue  is  common,  but  not  universal. 

The  duration  of  hooping-cough  is  seldom  less  than  six  weeks, 
although  cases  have  ended  within  three  weeks.  Often  it  lingers 
for  three  or  four  months  ;  in  one  case  I  knew  it  to  last  a  year. 

Complications.— Pneumonia,  collapse  of  the  lungs,  and  (as  a 
sequela)  phthisis,  are  the  most  likely  to  occur.  Deafness  from 
rupture  of  the  membrana  tympaui  during  the  violent  coughing, 
has  been  known.  Sometimes  the  eyes  become  bloodshot  from  the 
same  cause.  Convulsions  occasionally  increase  greatly  the  serious- 
ness of  the  disorder.  I  have  known  it  (as  above  mentioned)  to 
terminate  with  fatal  apoplexy. 

Causation  and  Pathology. — There  is  no  question  of  the  con- 
tagiousness of  hooping-cough.  Generally  it  occurs  but  once  in 
the  same  person ;  but  second  attacks  are  not  very  rare.  Like 
scarlet  fever,  measles,  etc.,  it  is  much  most  often  met  with  in 
children  ;  but  this  is  merely  from  their  susceptibility  under  expo- 
sure ;  as  adults  also  may  have  it. 

Belonging  with  the  zymotic  diseases,  and  caused  by  a  specific 
morbid  poison,  the  spasmodic  nature  of  the  cough  points  to  the 
nervous  system  as  in  main  part  the  seat  of  its  action.  Yet  the 
expectoration,  as  well  as  early  (and  afterwards  occasional)  febrile 
symptoms,  show  that  bronchial  inflammation  exists  secondarily 
at  least.  The  asserted  discovery,  by  Letzerich,^  of  a  fungoid 
vegetation  in  the  epithelium  of  the  air-tubes,  requires  confirma- 
tion. Similar  observations,  however,  are  reported  by  Buhl, 
Hiiter,  Tomasi,  Oertel,  and  Nasilofl".  Another  view  is,  that  the 
s])asmodic  aftection  may  be  produced  by  the  pressure  of  enlarged 
bronchial  glands  upon  the  pneumogastric  and  recurrent  laryngeal 
nerves. 

Treatment. — Mild  cases  need  only  care  to  avoid  exposure  to 
danii?  and  cold.     After  the  first  few  days,  if  there  be  no  fever  nor 

1  Quarterly  Journal  of  Microscopical  Science,  April,  1871. 


424  ZYMOTIC    DISEASES. 

soreness  of  the  chest,  the  patient  need  not  be  kept  in  the  house  in 
good  weather.  Indeed,  he  will  cough  least  when  most  out  of  doors. 
When  the  cough,  at  first,  is  tight  and  painful,  with  little  expecto- 
ration, syrup  of  ipecac  or  squills  may  be  given.  As  soon  as  the 
spasmodic  character  of  the  cough  declares  itself  with  some  vio- 
lence, the  "milk"  or  the  tincture  of  assafoetida  may  be  given, 
with  or  without  other  expectorants,  according  to  the  case  [F. 
153].  Severe  cases  may  be  quieted  by  belladonna  or  musk  ;  but 
I  have  been  especially  satisfied  with  the  effect  of  the  fluid  extract 
of  hyoscyaraus,  in  the  dose  of  from  four  drops  in  a  child  of  ten 
or  twelve  years  of  age,  down  to  a  fraction  of  a  drop  at  a  time  in 
a  young  infant  [F:  154, 155,  156] .  Atomizatwn  of  belladonna  has 
been  used  with  good  success  by  Dr.  Haynes.^  Coffee,  hydrocyanic 
acid,  bromide  of  ammonium  (from  two  to  twelve  grains  at  once 
for  a  child),  nitric  acid,  alum,  clover-tea,  chestnut-leaf  i&Si  (Unsicker, 
Davis)  or  fluid  extract  of  the  same,  oxalate  of  cerium,  and  ben- 
zoic acid,  are  among  the  remedies  often  employed  to  allay  the 
violence  of  the  paroxysms.  Application  of  strong  solution  of 
nitrate  of  silver  to  the  larynx  has  some  advocates.  Dr.  Gibb's 
preference  is  for  nitric  acid,  given  internally.  Dr.  De  Cailhol,  of 
St.  Louis,  has  reported  (1879)  a  rapid  cure  under  the  internal  use 
of  jaborandi.  Dr.  Bowles,  of  VirgUiia  {Va.  Med.  Monthly^  March, 
1881),  asserts  the  benefit,  in  a  severe  case,  of  inhalation  of  (a  few 
drops  at  a  time)  nitrite  of  amyl. 

Binz,'^  Dawson,  and  others  assert  decided  advantage  from  qui- 
nine, in  considerable  doses,  during  the  height  of  the  disease. 
Hydrate  of  chloral  is  said  by  Drs.  Lorey,  P.  B.  Porter,  and  others, 
to  be  of  great  value  in  this  affection.^  Inhalation  of  the  steam 
of  boiling  water  containing  ammonia  (f5J  of  strongest  liq.  ammon. 
in  a  gallon  of  water)  is  advised  after  the  third  week  by  Dr.  J. 
Grantham  [Brit.  Med.  Journal,  Sept.  16,  1871). 

In  protracted  cases  counter-irritation  to  the  chest  and  back  of 
the  neck  may  be  required.  I  once  met  with  great  relief  upon  the 
application  of  a  small  blister  to  the  nucha.  Tonics  are  also  not 
unfrequently  called  for  toward  the  end  of  the  attack  in  a  feeble 
child ;  especially  quinine  or  tincture  of  bark  (Huxham's),  iron, 
or  cod-liver  oil.  There  is  very  seldom  need  to  restrict  the  diet 
in  this  disease,  unless  during  the  first  week. 

Dr.  W.  S.  King  has  reported  several  cases  seeming  to  show 
that  the  air  of  gas-works,  freely  breathed,  is  curative  of  hooping- 
cough.* 

DIPHTHERIA. 

Synonyms. — Pseudo-membranous  Angina;  Putrid  Sore  Throat, 
Dijjhtheritis. 

History.— Though  the  name  diphtheria  (from  6c(f>depa,  a  skin  or 
membrane)  was  only  given  to  this  disease  by  Bretonneau  of  Tours 
less  than  sixty  years  ago,  it  appears  to  have  been  described  by 
Aretseus  of  Cappadocia  as  a  .disease  of  Egypt,  and  was  mentioned 

1  Phila.  Med.  Times,  April  25,  1874. 

2  Am.  Journal  of  Obstftrics,  May,  1870.    See  also  the  same  Journal,  Feb.,  1873. 
s  New  York  Med.  Journal,  Aug.,  1873. 

i  Phila.  Med.  and  Surg.  Keporter,  May  and  June,  1867. 


DIPHTHERIA.  425 

also  by  Macrobius  and  Coelius  Aurelianus  amonf?  early  writers. 
Hecker  gives  an  account  of'its  prevalence  in  Holland  in  WM ; 
Carnevale,  at  Naples,  1()2U  ;  Taniayo,  at  Madrid,  called  it  (/arotiUo^ 
in  1622.  Ghisi  first  clearly  described  the  pseudo-membranous 
formation,  at  Cremona,  1740.  In  France  Ohomel  saw  it  in 
1743-9 ;  in  Enj^land,  Fothergill  in  1754 ;  Douglas  of  Boston,  in 
this  country,  in  17:50  ;  and  Samuel  Bard  of  New  York,  in  1771. 
Iluxham,  Cheyne,  Rosen,  Albers,  and  Guersent  also  described  it 
under  different  titles.  Bret(mneau  most  fully  made  it  out  as  a 
distinctive  disease,  in  182G.  Since  that  time  it  has  been  recog- 
nized and  treated  of  by  nearly  all  medical  authorities. 

Later  epidemics  of  it  have  been  principally  those  of  Paris  and 
Boulogne  of  1855-7,  passing  to  England  in  the  latter  year ;  and 
of  our  own  country  beginning  in  California  in  1856,  and  in  the 
Eastern  States  a  little  later,  gradually  increasing  in  prevalence 
until  1860.  Since  that  time  it  has  rather  declined  in  frequency, 
although  still  existing,  and  sometimes  attended  by  great  local 
ftitality.  New  York  and  Brooklyn  have  suffered  severely  with 
it.  In  one  week  in  January,  1881,  there  were  168  cases  in  New 
Y'ork.  During  13  weeks  of  the  last  quarter  of  the  year  1880, 
Brooklyn  had  1185  cases  of  dipbtheria,  with  483  deaths.*  It  was 
terribly  destructive  in  some  parts  of  Russia  in  1879-80  ;  carrying 
off,  in  two  or  three  towns,  more  than  half  of  the  children.  Bre- 
tonneau,  not  unreasonably,  supposes  Washington  and  the  Empress 
Josephine  to  have  died  of  diphtheria.  Stephanie,  the  beautiful 
queen  of  Portugal,  and  the  Princess  Alice,  of  Hesse  (1879),  were 
victims  of  it. 

Varieties. — 1.  Simple ;  2.  Croupous  ;  3.  Ulcerative  ;  4.  Malig- 
nant diphtheria. 

Symptoms. — Premonitory,  but  not  distinctive,  are  general 
malaise^  slight  sore  throat,  and  swelling  of  the  lymphatic  glands 
behind  the  jaAv.  Then,  in  the  simple  form,  fever  occurs,  with 
headache,  furred  tongue,  constipation,  and  difficulty  of  swallow- 
ing. On  examination,  a  swollen  and  very  red  or  purple  appear- 
ance of  the  fauces  will  be  observed,  as  well  as  of  the  palate  and 
tonsils.  Over  one  or  both  of  the  latter  there  may  be  seen,  often 
as  early  as  the  second  or  third  day,  a  whitish  or  yellowish-white 
membranous  deposit.  All  the  symptoms  continue  in  this  form 
from  five  to  nine  days,  when,  in  favorable  cases,  convalescence 
follows. 

The  croupous  form  has  caused  the  greatest  number  of  deaths, 
especially  in  children.  This  seems  especially  prone  to  follow 
measles  or  scarlatina.  In  it,  after  the  same  early  symptoms  as 
those  above  described,  but  sometimes  with  violence  from  the 
beginning,  increase  of  discomfort  in  the  throat  is  complained  of. 
Then  an  abundant  yellow  or  brownish  leathery  exudation  is 
found  to  cover  the  tonsils  and  fauces,  which,  under  the  exuda- 
tion, are  much  swollen.  Often  quite  early  in  the  attack,  the 
pseudo-membranous  inflammation  extends  to  the  larynx.  This 
is  shown  by  the  usual  symptoms  of  croup  ;  the  barking  cough 
and  voice,  and  difficult  inspiration,  becoming  whistling  or  sibilant 

1  Sanitary  Engineer,  Dec.  15,  18S0. 
36* 


426  ZYMOTIC    DISEASES. 

when  the  obstruction  to  breathing  is  the  greatest.  A  fatal  ter- 
mination may  occur  by  asphyxia  in  a  very  few  days.  This  can 
only  be  averted  by  the  detachment  and  expulsion  of  the  mem- 
brane without  its  re-formation. 

The  ulcerative  variety  is  not  common.  When  destruction  of 
the  palate  and  tonsils  has  attended  it,  with  copious  dark-colored 
and  pulpy  exudation,  and  some  extravasation  of  blood,  it  has 
been  mistaken  for,  and  described  as,  gangrene  ;  whence  the  old 
name  "putrid  sore  throat."  The  occasional  existence  of  true 
gangrene  cannot  be  altogether  denied. 

Malignant  Diphtheria. — At  the  commencement  of  this,  there 
is,  with  intense  headache,  not  unfrequently  vomiting,  which  is 
uncommon  in  the  milder  varieties,  and  hemorrhage  from  the 
nose,  mouth,  stomach,  or  rectum.  Great  dysphagia  soon  exists, 
and  enormous  engorgement  of  the  submaxillary,  parotid,  and 
cervical  glands.  The  tonsils,  pharynx,  and  palate  are  covered 
thickly  with  a  leathery  deposit,  at  first  yellowish,  but  soon  becom- 
ing ash-colored,  brown,  or  almost  black,  and  of  an  offensive  odor. 
The  tonsils  may  suppurate  or  even  slough.  The  nostrils  are  also 
sometimes  involved,  being  swollen,  lined  with  false  membrane, 
and  emitting  an  acrid  and" fetid  discharge.  Extreme  prostration 
comes  on  at  a  more  or  less  early  period  ;  it  may  be  from  the  first 
day.  The  pulse  becomes  very  rapid,  the  face  lividly  pale,  mor- 
bid heat  of  the  skin  being  followed  by  clammy  coldness.  Coma 
often  precedes  death.  The  latter  may  take  place  in  three,  four, 
or  five,  occasionally  in  one  or  two  days  ;  sometimes  from  the 
constitutional  impression  of  the  disorder  before  the  local  affec- 
tion has  been  fully  developed. 

Special  Symptoms  and  Comi^licatioiis.— Albuminuria  is  pres- 
ent in  most  severe  cases  of  diphtheria,  from  an  early  time  in  the 
attack.  A  diphtheritic  affection  of  the  sMn  has  been  now  and 
then  observed.  A  blistered  or  otherwise  abraded  surface  will 
usually  in  the  course  of  the  disease  be  covered  by  false  membrane. 
Pneumonia  is  an  occasional  and  dangerous  complication.  Endo- 
carditis (Bouchut,  Lagrave)  is  not  rare,  although  its  symptoms 
may  be  masked  and  overlooked.  Heart-clot^  sometimes  makes 
death  certain,  in  an  otherwise  doubtful  case. 

Sequelae. — These  are  especially  long-continued  debility,  pa- 
ralysis of  the  soft  palate,  and  paralysis  elsewhere  in  various 
degrees.  In  this,  deglutition,  articulation,  vision,  and  locomo- 
tion may  be  involved.  A  fatal  result  may  occur  after  a  few 
weeks,  or  recovery  after  a  longer  period  ;  sometimes  from  two  to 
eight  months. 

Morbid  Anatomy. — The  pellicle  or  deposit,  formed  upon  the 
highly-injected  and  tumefied  mucous  membrane  of  the  fauces 
and  throat,  constitutes  the  anatomical  peculiarity  of  the  disease. 
Minutely  examined,  the  false  membrane  is  found  to  vary  from 
^th  to  ^th  of  an  inch  in  thickness,  and  to  be  fibro-laminated ; 
i.  e.,  of  layers  of  fibrinous  network,  including  epithelial  cells,  and 
having  on  its  free  surface  exudation  corpuscles  or  "  pyoid  glob- 
ules," and  granules;  these  forms  appearing  to  be  only  stages  of 

1  J.  F.  Meigs,  Am.  Journal  of  Med.  Sciences,  April,  1864. 


DIPHTHERIA.  427 

degeneration.  No  process  of  organization  or  development  occurs 
in  the  mass  ;  it  is  aplastic.  In  some  cases  only  a  granular  super- 
ficial infiltration  of  mucous  membrane  is  observed,  without  even 
distinct  filn-illation. 

The  common  deposit  of  diphtheria  differs  from  the  false  mem- 
brane of  simple  inflammatory  croup,  and  still  more  from  the 
"coagulable  lymph"  of  inflamed  serous  membranes,  in  being 
tliicker,  more  tough,  yellower,  and  less  capal)le  of  anything  like 
organization.'  (Dr.  B.  Sanderson  asserts  that  he  discovered 
evidence  of  development  of  the  exudation  in  one  or  two  speci- 
mens of  the  simple  form  of  dii)htheria.) 

Pathology. — Excluding  from  the  title  of  diphtheria  all  instances 
of  accidental  or  merely  inflammatory  "'diphtheritic  "  or  i)seudo- 
membranous  formations,  as  they  occur,  for  example,  in  croup  and 
scarlet  fever,  we  must  admit  that  there  is  a  special  zymotic  or 
"enthctic"  disease,  for  Avhich  the  name  is  appropriate  and 
should  be  reserved.  It  is  a  toxaimic  or  "  dyscrasial "  affection,  in 
which  the  morbid  change  in  the  blood  has  its  main  and  charac- 
teristic local  manifestations  in  the  throat.^ 

Ortel,  Letzerich,  and  others  have  asserted  the  constant  occur- 
rence of  a  microscopic  organic  formation  (bacterium  or  micrococcus) 
in  the  throat  in  diphtheria.  Other  competent  observers  have 
failed  to  find  any  such  organisms  in  well-marked  cases,  and  have 
found  them  also  in  cases  not  diphtheritic  ;  hence  concluding  that 
although  the  coincidence  of  their  presence  with  that  of  the  disease 
is  frequent,  not  being  universal,  it  cannot  be  causative  or  patk- 
ogenc'tic.  Drs.  H.  C.  Wood  and  Formad,  in  their  investigations 
(1880),  found  satisfactory  evidence  against  the  bacterial  origin 
of  diphtheria. 

Among  those  who  continue  to  assert  it,  Talamon^  reports  suc- 
cess in  cultivating  spores  from  diphtheritic  membrane,  and,  with 
them,  producing  false  membranes  by  inoculating  rabbits  and 
other  animals.  But  the  vexed  question  remains,  whether  only 
these  spores  were  transferred  from  the  seat  of  disease ;  or 
whether  their  presence  was  coincident  merely,  or  really  causa- 
tive of  the  afi'ection. 

Causation. — Not  doubting  the  existence  of  a  special  material 
cause,  yet  unknown  except  by  its  eflects,  we  can  only  say  further 
that  the  disease  is  generally  epidemic  or  endemic,  with  a  special 
tendency  to  limited  localization.  It  acts  with  intensity  in  con- 
fined centres ;  as,  a  small  village,  a  crowded  school,  a  tenement 
house,  a  numerous  family,  inflicting  therein  often  a  terrible  loss 
in  proportion  to  the  numbers  attacked  —  a  sort  of  domestic 
pestilence. 

Is  diphtheria  transmitted  by  contagion  ?  I  am  sure  that  it 
sometimes  is  so,  although  clearly  not  dependent  upon  that  mode 
of  propagation  in  its  epidemic  migrations.    The  certain  examples 

1  Bretonneau  long  since,  and  Dr.  Sanderson  a  few  years  ago,  imitated  the  diphthe- 
ritic exudation,  by  injecting  oil  of  cantliarides  into  the  throats  of  animals.  The  prin- 
cipal ditierence  was  in  the  manifest  tendency  to  organization  iu  the  cantharidal  p.seiido- 
mumbrane. 

2  Sir  W.  .Tenner  considers  the  absorption  of  septic  matter  from  tlie  throat  a  cause  of 
increased  danger  in  diphtheria,  as  well  as  in  scarlatina. 

3  See  Lancet,  April  9,  laSl. 


428  ZYMOTIC   -DISEASES. 

of  its  extending  from  one  person  to  another  are  few ;  but  I  have 
known  of  several  such.  Valleix,  the  celebrated  French  physi- 
cian, is  said  to  have  lost  his  life  in  this  way.  In  1880,  Dr.  San- 
ford  B.  Hunt,  of  Green  Point,  N.  Y.,  died  in  consequence  of 
blowing  through  a  tracheotomy-tube,  while  operating  upon  a 
patient.  The  instance  of  the  Princess  Alice  of  Hesse,  infected 
by  kissing  her  sick  child,  has  become  historical.  Such  cases 
suggest  precautions,  which  ought  always  to  be  enforced. 

Children  are  much  more  liable  to  diphtheria  than  adults. 
Climate  and  season  do  not  seem  to  affect  its  pi'evalence.  It  often 
shows  very  decided  preference  for  unhealthy  places,  where  filth 
or  crowd-poison  abounds. 

Conveyance  of  diphtheria  by  milk  has  appeared  to  be  proved 
in  one  or  two  instances  at  least.  (See  Lancet,  Jan.  11,  18*79.) 
W.  H.  Powers  traced  this  in  an  epidemic  in  Korth  London.  It 
has  been  suggested  that  possibly  a  disease  of  the  cow,  called 
''garget,"  may  have  to  do  with  its  origination;  but  this  whole 
subject  requires  further  investigation. 

Diagnosis. — From  scarlatina ,  diphtheria  is  distinguished  by  the 
absence  of  the  eruption,  and  of  the  peculiar  punctated  or  briek- 
dust-like  flush  of  the  throat,  and  "strawberry"  tongue.  That 
scarlet  fever  'predisjposes  to  diphtheria,  as  a  subsequent  attack,  is 
a  well-established  and  not  unimportant  fact. 

With  membranous  croup,  it  is  contrasted  in  the  following  man- 
ner. That  disease  is  a  sporadic  and  sthenic  local  phlegmasia, 
whose  general  symptoms  are,  as  much  as  in  any  inflammation, 
dependent  upon  the  local  affection  ;  while  diphtheria  is  a  consti- 
tutional disorder,  usually  epidemic,  in  which  the  local  symptoms 
are  secondary.  More  directly,  in  practice,  we  may  mark  the 
commencement  of  the  pseudo-membranous  deposit,  in  diphtheria, 
about  the  tonsils  and  pharynx ;  in  croup,  in  the  trachea  or  larynx. 
That  of  diphtheria  rarely  extends,  in  any  case,  below  the  larynx  ; 
that  of  croup,  not  unfrequently  even  into  the  bronchial  tubes. 
After  the  laryngeal  complication  or  extension  has  occurred  in 
diphtheria,  the  croupal  sj'^mptoms  are  really  the  same  as  those 
of  any  other  laryngeal  obstruction,  and  thus  are  not  different 
from  those  of  croup.  There  is  no  albuminuria  in  croup,  and  the 
sequela  of  paralysis  never  attends  recovery  from  it. 

Prom  thrush,  and  aphthce,  diphtheria  is  known  by  the  deposit 
being  much  larger  and  thicker,  never  vesicular,  and  mostly  duller 
in  color ;  and  attended  generally  by  more  severe  constitutional 
symptoms.  Thrush  begins  in  the  mouth ;  it  is,  moreover,  much 
more  uncommon  in  adults  than  diphtheria ;  and  is  never  epidemic. 

Prognosis.^ — Simxjle  diphtheria  is  not  very  dangerous  to  life. 
The  croupal  form  is  decidedly  so  ;  and  the  malignant  is  fatal  in  a 
large  majority  of  cases.  Insidiousness  is  a  trait  often  belonging 
to  the  disease  in  children ;  a  name  which  has  been  applied  by 
some,  for  that  reason,  is  "  creeping  croup." 

Treatment. — No  specific  remedy  having  been  discovered  for 
this  disease,  we  must  be  governed  in  our  tentative  treatment  of 
it  by  our  idea  of  its  nature ;  while  concluding  upon  its  therapeu- 
tics, finally,  through  experience.  Nothing,  it  may  be  confessed, 
is  very  satisfactory,  as  yet,  in  the  management  of  bad  cases  of 


D  I  P  II  T  II  E  R  r  A  .  429 

it.  All  agree  that  it  is  not  a  mere  local  inflammation,  but  a  sys- 
temic aflection  primarily ;  and  that  its  type  is  most  generally 
asthenic.  Much  dojiletion  is  therefore  not  to  be  thougbt  of.  I 
would  never  bleed  from  the  arm  in  diphtheria.  In  simple,  open 
cases,  I  liave  used  leeches  to  the  throat,  with  seemingly  decided 
advantage,  within  the  first  three  days.  Even  their  use,  however, 
must  be  exeeptiDual.  Moderate  purgation,  as  with  citrate  of 
magnesium,  or  Kochclle  salt,  at  the  very  beginning,  is  suitable 
in  the  simple  and  croupal,  though  perhaps  not  in  the  malignant 
form. 

Chlorate  of  potassium  is  a  favorite  medicine  with  many  in  this 
disease.  My  best  results  in  bad  cases  have  attended  its  early  and 
free  use.  An  adult  may  take  twenty  grains  in  solution  every 
three  hoiu's;  I  have  given  five  grains  every  two  hours  to  a  child 
five  or  six  years  old  [F.  156] .  Such  a  treatment  will  not,  of  course, 
need  to  be  continued  for  many  days. 

Tincture  of  chloride  of  iron  is  relied  upon  by  many ;  from  ten 
to  twenty  drops  every  three  hours  for  an  adult ;  with  or  without 
the  chlorate  of  potassium  [F.  157].  Prof.  Clar'  uses  sesquichlo- 
ride  of  iron  in  glycerin  ;  giving  half-teaspoonful  doses  of  a  mixture 
consisting  of  twenty  drops  of  "liquor  ferri  sesquichloridi "  in  two 
ounces  of  pure  glycerin.  Sulphate  of  quinine  is  also  given,  alone, 
or  at  the  same  time  with  the  above  remedies,  by  a  number  of 
practitioners ;  say,  of  quinine,  for  an  adult,  a  grain  every  two 
or  three  hours. 

Besides  these,  or  instead  of  them,  for  internal  use,  permanga- 
nate of  potassium  has,  after  trial  (C.  Bell),  the  recommendation 
of  some  observers.  A  drachm  of  it  may  be  dissolved  in  a  pint 
and  a  half  of  water,  a  fluidrachm  of  this  being  taken  every  hour. 
Chlorine  water  is  urged  by  others.  It  may  be  given  in  teaspoonful 
or  even  tablespoonful  doses  to  an  adult.  Sulphite  of  sodium,  ten 
grains  every  two  or  three  hours,  is  worth}^  of  trial  in  this  as  in 
other  zymotic  diseases :  and  carbolic  acid  likewise.  Trideau 
recommends  highly  copaiba  and  cubebs.'-  Guttmann's'^  treatment, 
with  pilocarpine  has  attracted  considerable  attention.  Dr.  Wendt, 
of  New  York,  has  followed  it,  with  reported  success,  giving  to 
an  adult  half  a  tablespoonful  every  hour  of  a  mixture  containing 
half  a  gi-ain  of  muriate  of  pilocarpin  in  four  ounces.  After  each 
dose  the  patient  also  took  half  an  ounce  of  sherry  wine  to  pre- 
vent depression.  Copious  expectoration  resulted,  and  usually 
free  perspiration.  Guttmann's  own  prescription  was  from  half 
a  grain  to  a  grain  in  an  eight-ounce  mixture,  which  also  con- 
tained half  a  drachm  of  pepsin  and  a  few  drops  of  hydrochloric 
acid.  He  insists  on  the  administration  of  wine  after  each  dose 
of  the  pilocarpin,  reducing  the  amount  of  wine,  of  course,  as 
well  as  of  the  medicine,  for  children. 

It  has  been  reasonably  suggested  that,  for  local  as  well  as 
general  effect,  medicines  should  be  given,  in  diphtheria,  in  small 
doses  frequently  repeated,  rather  than  large  doses  at  long  in- 
tervals. 

1  Practitioner,  July  1,  1871. 

2  Brit,  and  Foreign  Medico-Chirurg.  Review,  October,  1868,  p.  417. 
s  Berlin.  Kliu.  Wochenschr.,  Oct.  4,  1880. 


430  ZYMOTIC    DISEASES. 

More  heroic  modes  of  treatment  have  been  (1881)  proposed  and 
put  on  trial  in  diphtheria ;  e.f/.,  by  large  doses  of  oil  of  turpen- 
tine, of  bichloride,  and  of  cyanide  of  mercury.  A  priori,  there 
is  much  against  such  practice  ;  but  here,  as  elsewhere,  the  only 
required  test  in  medicine  is  experience. 

Concentrated  liquid  food  must,  as  a  rule,  be  given  throughout 
an  attack  of  diphtheria  (milk,  beef-tea,  and  very  often  wine  whey 
or  brandy  or  whisky  punch),  in  small  quantities  at  short  intervals, 
according  to  the  degree  of  prostration  present. 

Local  treatment  is,  by  most  physicians,  regarded  as  very  im- 
portant. Experience  has  shown,  I  think,  that  it  ought  not  to 
be  violent.  Ice  in  small  pieces,  melted  in  the  mouth  slowly,  is 
possibly  as  useful  as  any  application.  Muriatic  acid  and  honey, 
equal  parts,  applied  freely  with  a  large  camel's-hair  pencil,  or 
diluted  with  water  and  used  as  a  gargle,  I  believe  to  be  service- 
able. Creasote  dissolved  in  glycerin  [F,  158],  lime-water,  chlo- 
rinated soda  dissolved  in  twenty  parts  of  water,  diluted  carbolic 
acid,  and  permanganate  of  potassium  (a  drachm  in  a  pint),  make 
also  appropriate  gargles.  M.  Eevillout  (Gazette  des  Hupitaux, 
1874),  on  the  basis  of  long  experience,  recommends  pure  lemon- 
juice  for  this  purpose.  Dr.  Hotz,^  of  Chicago,  speaks  highly  of 
the  application  to  the  throat,  with  a  brush,  of  a  solution  of  a 
drachm  each  of  carbolic  acid  and  alcohol,  with  half  a  drachm 
of  tincture  of  iodine  and  five  drachms  of  water.  Dr.  J.  Lewis 
Smith'^  uses  the  following :  Acidi  carbolici,  gtt.  v  ;  Liq.  ferri  sub- 
sulphat.,  f3ij  ;  glycerinpe,  gj  ;  M.  This  is  applied  by  means  of  a 
brush.  Dr.  Clark,  of  Oswego,  eulogizes  the  use  of  the  liq.  ferri 
persulph.  alone.  Dr.  J.  L.  Smith  favors  also  the  use  of  lime- 
water  with  the  atomizer,  e.g.,  acid,  carbol.,  gtt.  xxxij  ;  glycerin., 
f,5ij  ;  aq.  calcis,  fjvj  ;  if.  Dr.  H.  Eeynolds^  has  used  with  suc- 
cess equal  parts  of  carbolic  acid  and  glycerin,  locally  applied. 
J.  A.  E.  Stuart,  of  Edinburgh,*  reports  the  curative  effect  of 
powdered  sulphur  blown  through  a  quill  upon  the  patches  of 
exudation.  Ciattaglia,  of  Kome,  asserts  excellent  results  from 
the  application  of  a  solution  of  chloral  in  five  times  its  bulk  of 
glycerin.  Iodoform  (local  application  of  the  powder)  ought  to  be 
tried  in  bad  cases  of  diphtheria,  on  account  of  its  admirable 
influence  upon  indolent  ulcerations  and  inflammations.  It  might 
be  blown,  in  small  amount  (its  dose  internally  is  about  one  grain), 
into  the  fauces  through  a  quill  or  other  tube.  Benzoate  of  sodium 
(used  internally  as  well  as  locally)  is  reported  by  Letzerich  to 
have  cured  twenty-six  out  of  twenty-seven  cases  of  diphtheria.* 
Drs.  Jacobi  and  Billington,  of  IsTcw  York,  insist  on  the  impor- 
tance of  frequently  syringing  out  the  throat,  and  the  nostrils  in 
nasal  diphtheria,  to  wash  away  the  offensive  exudation  and 
secretions.  Simple  tepid  salt  water  will,  according  to  Dr.  Bill- 
ington,*^ answer  for  this,  thrown  in  by  means  of  a  hard-rubber 
ear-syringe.    Dr.  W.  W.  Cleave,'  of  Louisville,  recommends,  after 

1  New  York  Med.  Record,  Aug.  15, 1871.  2  Ibid.,  April  1,  1874. 

^  Medical  News,  December,  1872.  4  Practitioner,  April,  1879. 

6  Berlin.  Klin.  Wochens.,  1879,  No.  7. 

6  New  York  Med.  Record,  March  27,  1880,  p.  335. 

7  LouisTille  Medical  News,  January,  1881. 


GLANDERS.  431 

trial,  the  local  application,  with  a  mop,  of  o(7  of  turpentine,  which 
is  said  to  penetrate  tin;  exudation  and  cause  its  separation.  Dr. 
I.  R.  Page,'  of  Baltimore,  states  that  1)(;  lias  found  fresh  lemon- 
juice,  applied  upon  a  camel's-hair  proljang,  the  most  efl'ective 
agent  to  promote  the  removal  of  tlie  membrane  from  the  throat 
in  diphtheria.  Chloroform,  similarlj-  applied,  is  recommended 
hy  Dr.  Lathrop,'  of  New  Hampshire.  In  a  young  child  ice  is 
sometimes  the  only  local  application  possible  without  a  struggle 
so  disturl)ing  as  to  make  the  benefit  of  it  doubtful.  Cold-water 
compresses  may  be  applied  outside  of  the  throat  in  the  early 
stage,  while  there  is  excess  of  heat.  Later,  flannel  wrung  out  of 
hot  water,  to  which  an  equal  amount  of  spirits  or  vinegar  has 
been  added,  will  give  more  comfort. 

Inhalation  of  the  steam  of  lime-water  is  worthy  of  continued 
trial  in  diphtheria,  especially  in  the  croupous  variety ;  or,  the 
atomization  of  lime-water  by  the  nephogene  or  some  other  appa- 
ratus constructed  for  the  purpose. 

1  am  convinced  that  the  eftbrt  (which  I  have  seen  practised)  to 
remove  the  patches  of  exudation  by  force,  as  by  excision  or  actual 
cauterization,  is  to  be  deprecated,  as  likely  to  do  harm  rather 
than  good. 

In  treatment  of  the  paralysis  which  sometimes  follows  diph- 
theria, strychnia  is  especially  appropriate,  but  here,  as  elsewhere, 
it  must  be  given  with  caution. 

GLANDERS. 

Synonym. — Equinia.  Though  not  common  in  the  human  sub- 
ject, it  is  important  to  know  that  this  afiection  can  be  taken 
from  the  horse.  It  is  said  to  occur  either  in  the  acute  or  the 
chronic  form,  generally  the  former. 

Symptoms  and  Course. — After  an  incubation  of  from  two  to 
seven  days,  with  febrile  symptoms,  the  nostrils  become  inflamed, 
and  at  the  same  time  pains  in  the  joints  occur,  like  those  of  rheu- 
matism. Over  parts  of  the  body  the  skin  becomes  red  in  patches, 
which  may  grow  dark  and  even  gangrenous.  Crops  of  pustules 
also  appear,  one  after  another,  on  the  face  and  limbs.  In  the 
course  of  a  week  or  so  a  muco-puruleut  discharge  comes  from 
the  nostrils,  which  are  swollen,  ulcerated,  or  gangrenous.  The 
fauces,  pharynx,  larynx,  even  the  lung,  may  become  seriously 
involved.  The  face  and  eyes  inflame  and  become  (edematous. 
Throughout,  fever  of  a  low  form  continues,  with  great  thirst, 
delirium  or  coma,  a  fetid  odor  from  the  skin,  and  diarrhoea. 
Death  almost  always  occurs  within  three  weeks,  sometimes  one 
or  two  weeks  later. 

Chronic  glanders  is  rare  ;  it  is  described  as  milder  than  the 
above,  and  much  less  fatal. 

Treatment. — This  must  be  purely  tentative.  Most  worthy  of 
trial  are  carbolic  acid  and  the  sulphites,  as  sulphite  of  sodium, 
and  bcnzoatc  of  sodium,  with  a  supporting  diet  of  milk,  beef-tea, 

»  New  York  Med.  Record,  May  7,  1881,  p.  530. 
■■^  Phila.  Med.  Times,  May  22,  1881,  p.  533. 


432  ZYMOTIC    DISEASES. 

etc.     Locally,  I  would  use  creasote  or  carbolic  acid  dissolved  in 
glycerin — dilute  chlorinated  soda  and  lime-water. 

INFLUENZA. 

Synonym. — Epidemic  Catarrh. 

History. — Although,  among  persons  exposed  to  the  same 
weather,  catarrhal  affections  are,  of  course,  common  at  certain 
times,  there  is  evidence  that,  apart  from  the  conditions  of  humid- 
ity and  temperature  of  the  air,  epidemic  catarrh  sometimes  occurs 
as  a  zymotic  disease.  It  is  recorded  as  having  been  quite  fatal 
in  France  in  1311  and  1403  ;  in  1570  also  it  prevailed,  and  in  1557 
spread  over  Europe  and  extended  to  America.  It  occurred  again 
in  17-29,  '43,  '75,  '82,  1833,  '37,  with  notable  violence.  In  the 
United  States,  one  of  the  most  remarkable  epidemics,  for  extent, 
was  that  of  1843.  Another  was  that  of  1872,  following  nearly 
the  course  of  the  epizootic  amongst  horses  of  the  latter  part  of 
that  year.  The  local  prevalence  of  influenza  may  occur  at  very 
irregular  periods,  and  sometimes  so  mildly  as  not  to  be  distin- 
guished from  common  sporadic  catarrh. 

Symptoms  and  Course. — The  ordinary  symptoms  of  "a  bad 
cold"  are  those  of  influenza,  but  the  illness  of  the  latter  is  some- 
what more  severe,  and  prostration  is  generally  greater.  Of  this 
there  are  all  grades,  however.  Bronchitis,  sometimes  capillary, 
and  pneumonia,  are  not  rare  complications.  Old  people  are 
especially  apt  to  be  carried  off  by  influenza.  Its  mortalit}'-  is 
very  small  among  persons  in  early  or  middle  life.  The  duration 
of  an  attack  is  commonly  from  three  to  ten  days. 

Causation. — The  hypotliesis  has  been  entertained,  in  conse- 
quence of  the  irritating  eftect  of  ozone  upon  the  air-passages,  that 
an  excess  of  it  in  the  atmosphere  may  be  the  cause  of  influenza. 
But  no  facts  raise  this  supposition  beyond  conjecture. 

Treatment. — Mild  cases  require  housing,  and  little  more.  A 
warm  mustard  foot-bath  at  night,  followed  by  a  large  draught  of 
hot  lemonade  if  there  be  chilliness,  or  the  saiue  taken  cold  if 
fever  exist,  and  a  dose  of  solution  of  citrate  of  magnesium  or 
Eochelle  salt  or  senna-tea  in  the  morning,  will  generally  suffice. 
Sweet  spirit  of  nitre  may  be  added  to  the  night-draught  if  the 
skin  be. dry  and  the  urine  scanty. 

Great  prostration,  especially  in  old  people,  may  call  for  support 
by  quinine  and  stimulants.  Hot  whisky  punch  is,  for  such  a  case, 
not  out  of  place.  The  abortion  of  an  attack  of  influenza  is  some- 
times practicable  within  the  first  day  or  two,  by  giving  quinine,  in 
four-  or  five-grain  doses,  thrice  daily.  Bronchitis  or  pneumonia, 
as  complications,  will  require  treatment  as  in  other  cases. 

DENGUE. 

Synonym. — Brealc-hone  Fever. 

History. — ^Frequently  in  the  Southern  United  States,  occasion- 
ally in  the  N'orthern  (at  least  Dr.  Rush  seems  to  have  described 
it  at  Philadelphia  in  1780),  and  in  Egypt  and  the  East  and  West 
Indies,  this  disorder  has  occurred.  Some  English  writers  regard 
it  as  a  variety  of  scarlet  fever  ;  naming  it  Scarlatina  rheumatica. 


INTERMITTENT    FEVER.  433 

In  Chai'leston  (L'^.jO)  there  were  10,000  cases  of  it ;  in  the  summer 
of  1K80,  between  '2000  and  3000  ;  without  any  deaths. 

Symptoms  and  Course. — Usually  after  a  chill,  fever  comes  on, 
moderate  in  d(;<j;n'e,  but  attended  by  flushed  face,  bitter  taste  in 
the  mouth,  considerable  debility,  soreness  of  the  muscles,  and 
severe  pains  in  the  head,  back,  and  joints  ;  the  latter  being  some- 
what swollen.  In  about  two  days,  or  less  (sometimes,  however, 
five  or  six  days),  the  fever  subsides,  and  the  pains  lessen,  though 
they  do  not  disappear.  Toward  the  end  of  a  week  from  the  com- 
mencement of  the  attack,  a  rash  breaks  out,  resembling  that  of 
scarlatina,  of  duller  hue,  and  more  in  patches  ;  occasionally  with 
sudamina  also.  The  fever  often  returns  about  the  fourth  or  fifth 
day,  and  lessens  or  ceases  after  the  eruption  has  come  out.  All 
tlie  symptoms  gradually  subside,  leaving  the  patient  well  but 
very  weak,  by  the  beginning  or  middle  of  the  second  week  of  the 
attack.  This  disease,  without  complication,  is  never  fatal;  nor 
does  it  leave  any  sequelae  except  debility.  Possibly  akin  to  it 
may  be  acrodynia,  described  by  M.  Lannois^  as  occurring  epi- 
demically in  France  in  1828, 1829,  and  1830.  Its  chief  symptoms 
are  vomiting,  diarrhoea,  oedema  of  the  limbs,  redness  or  splotches 
of  the  hands  and  feet,  pain  and  burning  sensations  or  numbness 
In  the  palms  and  soles ;  sometimes  cramps  and  loss  of  power. 

As  sequelce  of  dengue.  Dr.  Forrest,'-  of  Charleston,  mentions 
excessive  and  obstinate  prostration,  sleeplessness,  night-sweats, 
anaemia,  hysteria,  neuralgia,  diarrhoea,  boils  and  carbuncles, 
conjunctivitis,  bronchial  catarrh,  deafness,  aphonia,  oedema, 
icterus,  cystitis,  rheumatism,  and  temporary  paralysis  of  the 
lower  limbs. 

Its  causation  is  not  known,  beyond  what  is  comprised  under 
the  term  "epidemic  influence."  It  is  noticeable  that  it  affects 
more  persons  at  one  place  and  time  than  almost  any  other  epi- 
demic :  nearly  all  the  population  may  have  it  in  one  season  ;  all 
ages  and  both  sexes  being  alike  attacked. 

In  treatment,  dengue  requires  merely  good  nursing — regulating 
the  bowels,  and  relieving  or  mitigating  the  pains  with  Dover's 
powder  or  other  opiates,  especially  at  night ;  or  by  the  local 
application  of  laudanum,  etc. 

MALARIAL   FE7ER. 

Varieties. — Intermittent,  Remittent,  and  Pernicious  Fever.  These 
may  all  be  properly  regarded  as  grades  or  modifications  of  the 
same  type  of  disease  ;  agreeing  in  the  nature  of  their  cause,  the 
periodicitj^  of  their  symptoms,  and  their  mutual  convertibility. 
Each  will,  however,  require  a  separate  description. 

INTERMITTENT  FEVER. 

Synonyms. — Ague:  CJiiJls  and  Fever. 

Varieties. —  Quotidian,  when  the  paroxysm  occurs  every  day; 
tertian,  when  it  is  every  other  day  ;  quartan,  on  the  first  and 

1  Paralysie  Vaso-ilotrice  des  Extremites,  etc.,  Paris,  1880. 
-  Amer.  Journal  of  Med.  Sciences,  April,  1881,  p.  333. 

37  2*^ 


434  ZYMOTIC    DISEASES. 

fourth  days  ;  also,  quintan,  sextan,  septan,  and  octan.  The  quo- 
tidian and  tertian  are  common  ;  the  octan,  or  weekly  return  of 
the  attack,  is  not  unfrequently  met  with ;  the  others  are  very 
rare.  The  time  between  two  paroxysms  is  called  the  intermission 
(apyrexia);  the  period  from  the  beginning  of  one  chill  to  the 
beginning  of  the  next  is  the  interval.  Paroxysms  are  sometimes 
double:  as,  double  quotidian,  with  two  paroxysms  on  one  day; 
double  tertian,  with  a  paroxysm  every  day,  but  those  of  every 
other  day  corresponding  in  time  or  character,  etc.  These  also 
are  rare.  I  have,  in  a  large  number  of  cases  of  malarial  fever,  in 
the  suburbs  of  Philadelphia,  never  met  with  a  double  paroxysm 
of  either  type. 

Symptoms  and  Stages. — N'o  disease  has  ordinarily  so  regular 
a  succession  of  definite  stages  as  intermittent  fever;  viz.,  the 
cold,  the  hot,  and  the  sweating  stage. 

Cold  Stage,  or  Chill. — Beginning  with  languor  and  yawning,  a 
sensation  of  coldness  comes  on,  often  creeping  and  shivering,  with 
chattering  of  the  teeth  and  rigors  or  tremulous  movements.  The 
skin  has  a  sunken  appearance,  and  the  lips  and  finger-ends  may 
be  blue.  The  sense  of  coldness  does  not  prove  a  low  temperature 
of  the  body ;  which  the  thermometer  sometimes  shows  to  be  even 
hotter  than  natural.  Thirst  exists,  with  loss  of  appetite  ;  occa- 
sionally, vomiting.  Headache,  depression  of  spirits,  and  drowsi- 
ness are  common.  Perspiration  is  absent,  but  the  urine  is  abundant 
and  nearly  colorless,  with  a  low  specific  gravity.  The  duration 
of  a  chill  varies  from  ten  minutes  to  two  or  three  hours ;  averaging 
not  more  than  three-quarters  of  an  hour. 

Hot  Stage ;  pyremt.— Gradually  warmth  is  felt  to  return  ;  the 
shivering  ceases  ;  a  flush  succeeds  the  pallor  or  lividness  of  the 
face.  A  real  increase  of  the  heat  of  the  surface  is  found  by  the 
thermometer ;  sometimes  reaching  105°  to  110°;  seldom  more  than 
108°.  The  mouth  becomes  dry,  the  tongue  furred  ;  vomiting  is 
common,  with  total  anorexia.  Headache  is  apt  to  be  violent ;  but 
delirium  is  rather  exceptional.  The  pulse  is  accelerated,  and 
generally  strong  and  full.  The  bowels  are  constipated ;  the  skin 
dry,  the  urine  scanty  and  high-colored.  The  hot  stage  may  last 
from  an  hour  or  two  to  sixteen  or  eighteen  hours. 

Sweating"  Stage. — This  also  comes  on  gradually;  the  face  first 
becoming  moist ;  then  the  trunk  and  limbs.  This  is  attended  by 
increased  comfort;  the  headache  lessens,  thestomach,  if  disturbed, 
becomes  quiet,  the  patient  often  goes  to  sleep  and  sweats  profusely 
all  over.  After  this,  the  fever  disappears  ;  the  pulse  is  slow  and 
soft,  the  skin  cool.  The  urine  now  is  passed  freely,  and  deposits 
a  brick-dust-like  (lateritious)  sediment.  There  is  no  definite 
length  of  time  to  be  assigned  to  the  sweating  stage. 

Of  the  three  stages,  now  and  then  one  or  two  may  be  wanting. 
There  is  then  only  a  chill,  or  a  fever,  or  a  sweat,  occurring  daily, 
or  every  other  day,  at  the  same  hour.  Or,  a  paroxysm  of  pain 
may  occur  in  one  part  of  the  body  with  the  same  regularity. 
One  form  of  this  is  called  "  brow  ague."  Dumb  ague  is  a  popu- 
lar name  for  an  attack  in  which  the  chill  is  absent  or  obscure, 
the  other  symptoms  recurring  periodically.  There  seems  to  be  no 
doubt  that  a  single  limb,  or  even  a  single  finger,  may  go  through 


INTERMITTENT    FEVER.  435 

all  the  three  stages — cold,  hot,  and  sweating  ;  the  rest  of  the  body 
being  unatlccted.  Intcjrniittcnt  ncMraUjia  is  very  common  in 
malarial  districts,  especially  after  chills  and  fever.  In  the  same 
regions,  all  complaints  are  apt  to  take  on  periodicity  ;  so  we  may 
have  intermittent  dysentery,  pneumonia,  etc.^ 

The  intermission  is  often  a  time  of  apparent  health,  except  for 
some  debility,  and  perhaps  headache  and  want  of  appetite  and 
of  good  digestion. 

Tlie  greater  number  of  paroxysms  of  intermittent  occur  in  the 
daytime.  An  attack  which  began  as  a  tertian,  may  become  a 
quotidian  ;  or  the  converse  may  happen.  Intermittent  sometimes 
passes  into  remittent  fever  ;  though  much  less  often  than  remit- 
tent becomes  intermittent. 

Sequelae. — Protracted  intermittents  are  often  accompanied  or 
followed  by  anaemia  of  a  marked  character,  and  by  enlargement 
of  the  spleen  and  liver  ;  especially  of  the  former.  Dropsy  is  a 
quite  frequent  result  of  these  visceral  aflections  and  of  the 
anaemia. 

Morbid  Anatomy. — Melancumia,  or  pigmentary  degeneration  of 
the  blood-corpuscles,  with  extravasation  and  deposit  of  pigment 
granules  in  the  liver,  spleen,  kidneys,  brain,  etc.,  is  almost  a 
characteristic  of  malarial  disease.  Enlargement  and  softening 
of  the  spleen,  and  engorgement  of  the  liver,  with  a  bronzed 
appearance  of  it,  are  the  only  other  peculiar  changes  of  structure. 

Diagnosis. — One  chill  can  hardly  ever  be  certainly  pronounced 
to  be  malarial,  because  very  many  acute  disorders  begin  with  a 
cold  stage.  Tioo^  with  a  distinct  apyrexia,  cannot  often  be  con- 
founded with  anything  else,  except  hectic  fever.  In  the  latter, 
there  is  usually  a  known  cause  for  the  symptomatic  febrile  symp- 
toms ;  the  patient  is  weak  and  emaciated,  the  paroxysm  is  irregu- 
lar in  time  and  duration,  there  is  a  bright  roseate  flush  upon  the 
cheek,  and  headache  is  usually  absent. 

Prognosis. — Left  to  itself,  intermittent  will  sometimes  get  well 
as  early  as  the  seventh,  eighth,  or  ninth  paroxysm  ;  more  often, 
it  will  last  ten  weeks  ;  sometimes  for  as  many  or  more  months. 

When  under  treatment,  it  is  almost  always  possible  to  break 
the  chills  by  quininization  or  cinchoni-zation  ;  but  they  frequently 
return  :  especially  at  the  end  of  one,  two,  or  three  weeks.  It  is 
a  good  sign  lor  the  paroxysm  to  occur  later  and  later  in  the  day, 
and  to  become  shorter  and  shorter.  Tertian  ague  is  generally 
the  most  readily  cured  ;  quartan  the  most  intractable,  though 
comparatively  uncommon.  Death,  in  modern  times,  since  the 
discovery  of  the  properties  of  Peruvian  bark,  almost  never 
happens  from  the  ordinary  type  of  intermittent ;  the  'pernicious 
form  is  very  dangerous.  Of  this,  something  will  be  said  upon 
another  page. 

Pathological  Nature. — As  to  this,  it  is  possible  only  to  specu- 
late at  present.  It  is  most  probable  that  ague  is  a  toxcemic 
neurosis.  The  importance  of  the  blood-change  attending  it  is 
shown  by  the  (melantemic)  disintegration  of  the  blood-corpuscles 

1  Mularial  puerperal  fever  was  described  in  the  Virginia  Med.  and  Surg.  Journal,  in 
1855,  by  Dr.  0.  F.  Manson. 


436  ZYMOTIC    DISEASES. 

(Frerichs,  Meigs)  and  deposit  of  pigment  in  various  organs. 
Bence  Jones,  Rhoads  and  Pepper'  found  the  natural _^MOrescence 
of  the  blood  to  be  diminished  during  malarial  attacks,  and  to  be 
restored  under  the  influence  of  quinine  upon  the  system. 

Causation. — Upon  the  origin  of  malarial  fevers,  the  following 
facts  seem  to  be  established  : — 

1.  They  are  reasonably  designated  as  autumnal  fevers,  because 
very  much  the  largest  number  of  cases  occur  in  the  fall  of  the 
year.     Spring  has  the  next  greatest  number  of  cases. 

2.  They  are  always  strictly  localized  in  prevalence. 

3.  They  never  prevail  in  the  old  and  thickly  built  portions  of 
cities. 

4.  An  average  summer  heat  of  at  least  60°  for  two  months  is 
necessary  to  their  development.  Their  violence  and  mortality  are 
greatest,  however,  in  tropical  and  sub-tropical  climates.'^ 

5.  They  prevail  least  where  the  surface  of  the  earth  is  rocky  ; 
and  most  near  marshes,  shallow  lakes,  and  slow  streams.  The 
vicinity  of  the  sea  is  free  from  them,  unless  marshes  lie  near 
it. 

6.  The  draining  of  dams  or  ponds,  and  the  first  breaking  or 
culture  of  new  soil,  often  originates  them. 

7.  Their  local  presence  in  the  autumn  is  always  checked  by  a 
decided  frost. 

Upon  these  facts  it  was  a  legitimate  hypothesis  (urged  espe- 
cially by  the  late  Prof.  J.  K.  Mitchell,  of  iPhiladelphia),  that  the 
material  cause  of  malarial  fevers  is  a  minute  vegetable  organism, 
whose  substance  or  emanations  enter  the  body.  Professor  Han- 
non,  of  Brussels,  relates  that  he  learned  in  1843  from  Prof.  C. 
Morsen,  and  verified  the  statement  in  his  own  person,  that  the 
exhalations  of  certain  fresh-water  algae  would  produce  ague. 

Dr.  Salisbury,  of  Ohio,  recorded  in  the  January  number  of  the 
American  Journal  of  Medical  Sciences  for  1866,  some  observations 
and  experiments,  tending  to  show  that  minute  cryptogamic  plants 
of  the  family  of  Palmellse,  abounding  over  the  surface  of  marshes, 
can  generate  intermittent  fever,  when  transported  to  localities 
otherwise  free  from  it.  Klebs  and  Tommasi-Crudelli  assert^  the 
discovery,  in  the  soil,  water,  and  air  of  the  malarious  Agro 
Romano,  of  a  peculiar  microscopic  fungus,  capable  of  producing 
intermittent  fever  in  animals  by  inoculation  ;  to  which  they  give 
the  name  Bacillus  malarice.  Such  results  require  of  course 
repeated  investigation  to  make  them  actually  matters  of  demon- 
stration. If  confirmed  by  such  means,  they  will  make  a  very 
•important  contribution  to  etiology.* 

Treatment. — One  remedy,  in  this  disease,  overshadows  all 
others  ;  cinchonism.  By  this  we  mean  the  production  of  the 
constitutional  impression  of  the  cinchona  bark,  or  of  one  of  its 
essential  constituents.     At  any  stage  it  appears  to  be  safe,  even 


1  Penna.  Hospital  Reports,  1868,  p.  269. 

2  Of  1,855,034  deaths  from  all  causes  in  British  India,  in  1869,  824,256  (nearly  half) 
resulted  froiu  "  bilious  fever." 

azeitsehrift  fur  Med.  etc.,  July,  1879. 

*See  Am.  Journal  of  Med.  Sciences,  Oct.,  1868,  p.  333,  for  an  attempted  refutation  of 
Dr.  Salisbury's  theory,  by  Prof.  H.  C.  Wood. 


INTERMITTENT    FEVER.  437 

at  the  height  of  the  pyrexia.  Nor,  as  a  rule,  is  any  special  prep- 
aration necessary. 

It  is  well,  always,  during  tlu^  chill,  to  promote  speedy  reaction 
by  external  warnitli,  and  perhaps  by  hot  drinks,  of  a  not  too 
stimulating  character.  The  bowels  ought  to  be  opened  well;  and 
the  fever  may  be  palliated  by  the  free  drinking  of  cold  water, 
made  more  diaphoretic  by  the  addition,  if  necessary,  of  neutral 
mixture  (citrate  of  potassium)  or  ellervescing  draught.  Then, 
as  soon  as  sweating  fairly  begins,  the  quinia,  ciuchonia,  quinidia, 
dextro-quinia,  or  bark  in  substance,  may  be  prescribed. 

The  sulphate  of  quinine  has  the  most  universal  reliance.  Some 
give  it  in  doses  of  several  grains  each,  twice  daily.  I  think  expe- 
rience warrants  me  in  preferring  to  give  one  grain  every  hour 
\F.  2, 159] .  The  amount  required  in  the  intermission  of  ordinary 
intermittent  is  about  15  grains.  Less  may  often  cure,  but  can 
hardly  be  depended  on.  The  quinine  may  be  given  in  pill  or  in 
solution.  I  advise  that,  in  tertian  ague,  the  patient  begin  early  on 
the  day  of  the  intermission,  and  take  one  grain  every  hour  till  he 
has  taken  twelve  grains.  The  next  day  let  him  begin  at  the  same 
rate,  and,  if  no  chill  occur,  take  ten  grains.  The  third  day,  nine  ; 
and  so  diminishing  daily  until  six  grains  are  reached.  Let  this 
be  continued  till  a  week  from  the  last  chill,  when  a  greater  ten- 
dency to  return  will  exist ;  on  that  day  let  ten  grains  again  be 
given.  After  that  time,  if  no  paroxysm  has  occurred,  he  is,  for 
the  time  at  least,  well. 

Sulphate  of  cinchonia,  in  doses  one-half  greater  (gr.  jss  instead 
of  one  grain)  [F.  160,  IGl]  has  always  succeeded  with  me,  in  a 
considerable  number  of  cases ;  as  it  has  with  others.  It  gen- 
erally produces  much  less  ringing  in  the  ears  than  quinine,  and 
can  be  taken  by  some  whose  heads  do  not  well  bear  that  medi- 
cine. Quinidia,  quinoidine,  dextro-quinine,  and  other  extractives 
of  bark  I  have  not  tried.  Considerable  favorable  experience  with 
them  is  recorded.  Dr.  Joseph  Dougall,  of  the  Madras  army,* 
treating  108  cases  with  the  different  alkaloids,  found  their  order 
of  efficacy  to  be  as  follows :  1.  Quinine.  2.  Quinidia.  3.  Cincho- 
nidia.  4.  Cinchonia,  Bark  in  substance,  especially  Calisaya 
bark  (an  ounce  in  the  intermission),  is  of  course  perfectly  reli- 
able ;  but  it  is  disagreeable  and  oppressive  to  tlie  stomach,  and 
should  only  be  used  when  its  derivatives  cannot  be  obtained, 
Dr,  S.  Ashurst,^  of  Philadelphia,  reports  excellent  results  with 
the  alkaloid  cinchonid,  given  in  powder  (1  grain  of  cinchonia,  4 
grains  of  sugar  of  milk,  ^g  of  a  grain  of  bicarbonate  of  sodium).. 
Having  no  water  of  crystallization,  its  dose  is  about  the  same  as 
that  ot  sulphate  of  quinia,  and  its  cost  is  much  less. 

Other  remedies  in  considerable  number  have  obtained  more  or 
less  reputation  in  the  treatment  of  ague.  Opium,  given  in  full 
dose  (say  GO  drops  of  laudanum)  shortly  before  the  time  of  an 
expected  chill,  has  been  found  generally  to  abort  it,  Liud  and 
others  have  even  given  opium  at  the  beginning  of  the  hot  stage. 
This  seems  contrary  to  ordinary  therapeutic  experience  in  other 

1  Edinburgh  Med.  Journal,  September,  1873. 

2  Am.  Journal  of  Med.  Sciences,  April,  1878,  p.  579. 

37* 


438  ZYMOTIC    DISEASES. 

analogous  cases.  Arsenic  (10  drops  of  Fowler's  solution  thrice 
daily)  is  considered  to  approach  very  nearly  in  certainty  to  the 
preparations  from  cinchona.  Sulphate  of  copper  is  asserted  by 
some  (in  ^-grain  doses)  to  be  anti-periodic  ;  and  so  is  nitric  acid 
(10  drops  thrice  daily,  diluted) ;  and  common  salt  (a  drachm  at  a 
dose,  half  an  ounce  during  an  intermission).  Dogwood  bark ; 
pepper  and  its  extractive,  piperin ;  willow  bark,  and  salicin 
obtained  from  it,  have  also  some  reputation  of  the  same  kind. 
Bromide  of  potassium  has  been  found  successful  at  Guy's  Hos- 
pital.^ Hydrobromate  of  quinia,  subcutaneously  injected,  was 
found  by  Gubler  and  Raymond  (Hopital  Beaujon,  Paris)  very 
efficient  (IJ  grains  injected  in  solution  four  times  daily).  Chloro- 
form, taken  by  the  mouth,  has  been  used  with  success  by  Dr. 
Merrill.  He  gives  f3j  at  once,  at  the  beginning  of  the  chill.  It 
may  be  diluted  with  mucilage.^  Picric  acid  and  picrates  (Ash- 
land) are  said  to  have  succeeded  when  quinine  had  failed. 
Carbolic  acid  has  been  employed  in  the  Mauritius  by  Barraut, 
and  by  Treulich  in  Germany.  In  Manilla,  the  dita  bark  (Echises 
scholaris)  has  been  found  efficacious.  Powder  of  the  fire-dried 
gi'een  leaves  of  Laurus  nobilis  is  said,  in  gramme  (15.5  grains) 
doses,  to  have  cured  obstinate  cases.  Polli,  and,  later,  Ronzani,* 
found  sulphite  of  magnesium  curative,  in  30-  to  60-grain  doses, 
taken  thrice  daily.  Dr.  Chubb,*  of  Cambridge,  Mass.,  arrested 
the  paroxysm  in  twenty-five  out  of  twenty-seven  cases  with 
hyposulphite  of  sodium.  In  Australasia  the  leaves  of  the  Euca- 
lyptus globulus  are  used ;  as  well  as  eucoJyptol,  a  liquid  camphor, 
obtained  from  that  tree.  A  strong  impression  of  almost  any 
kind  upon  the  system,  during  the  apyrexia,  may  arrest  or  pre- 
vent the  paroxysm.  So  may  act  the  drawing  of  a  blister  upon 
the  spine ;  or  a  cold  shower  bath.  Saunders,  of  India,  found 
inhalation  of  2  drops  of  nitrate  of  amyl  to  abort  the  chill.  I 
have  known  one  case  to  be  cured  by  the  patient  being  solemnly 
assured  (without  medicine)  by  a  quack  that  "he  would  never 
have  another  chill." 

But  the  breaking  or  interruption  of  chills,  though  generally 
curative  of  a  first  attack,  is  not  nearly  always  so  in  a  second  or 
third. 

Chronic  intermittent  may  maintain  a  constant  tendency  to 
relapse  in  spite  of  cinchonism.  In  such  a  case  anceynia  and  the 
malarial  cachexia  are  usually  present.  Here  the  great  remedy 
is  iron.  This  has  never  disappointed  me ;  that  is,  I  have  never 
failed  to  cure  a  case  of  uncomplicated  chronic  intermittent,  even 
of  several  months'  duration,  by  breaking  the  chills  first  with 
quinine,  and  then  causing  the  patient  to  persevere  for  a  month 
or  two  with  iron.  I  prefer  the  pill  of  the  carbonate,  Yallet's 
mass ;  three  grains,  with  a  grain  of  quinine,  in  each  pill 
[F.162]. 


1  British  Med.  Journal,  June,  1870. 

2  Pollacion  and  others  in  Spain  have  found  the  internal  use  of  chloroform  successful 
in  intermittent.  Bonafont  reports  the  cure  of  fifteen  cases  hy  inhalation  of  chloroform, 
— Dublin  Qiiar.  Journal,  of  Med.  Sci.,  February,  1867,  p.  167. 

3  Annali  di  Medicina,  November,  1870. 

*  Am.  Journal  of  Med.  Sciences,  April,  1868. 


REMITTENT     FEVER.  489 

REMITTENT  FEVER. 

Synonym. — BHinm  Fercr.    ■ 

varieties. — Simple  and  malignant.  The  latter,  however,  will 
be  de.scribed  under  rernicioufi  Fercr. 

Symptoms  and  Course. — Altlmu^h  the  premonitory  stage  is 
u.sually  short,  and  not  un frequently  wanting,  its  general  oceur- 
renee  is  well  established.  Its  syniptonis  are  those  of  general 
malaise,  with  some  headache,  slight  nausea,  and  furred  tongue. 
These  increase  until  a  chill,  not  violent,  but  lasting  sometimes  half 
an  hour  or  an  hour,  fiiirly  begins  the  attack.  Or,  an  ill-defined 
cold  stage,  with  a  feeling  of  chilliness,  languor,  and  debility,  per- 
haps cerebral  oppression  and  gastric  disorder,  may  occur. 

After  this,  the  febrile  condition  is  developed.  The  skin  b-^comes 
hot,  dry,  and  harsh  ;  the  ^H<?.se  rises  in  force  and  frequency, 
although  less  hard  and  tense  than  in  some  diseases,  and  not 
exceeding  generally,  during  the  first  exacerbation,  110  or  115 
beats  in  the  minute.  The  face  is  flushed;  headache  is  throbbing 
and  severe  ;  the  faculties  being  unfitted  for  any  mental  exercise. 
Violent  imin  is  almost  always  felt  in  the  back,  and  very  often 
also  in  the  limbs.  Epigastric  uneasiness  is  nearly  universal ; 
nausea  and  vomiting  extremely  common.  Bilious  matter  is  in 
many  instances  ejected  from  the  stomach.  The  boiuels  are  cos- 
tive ;  when  opened,  however,  the  stools  are  colored  with  bile. 
The  urinarij  secretion  is  scanty.  Thirst  is  always  great ;  cold 
drinks  ])eing  much  preferred.  Itesijiration  is  hurried,  although  free. 

After  a  continuance  of  from  eight  to  twenty  hours,  these 
symptoms  abate  more  or  less,  even  without  treatment.  The 
feelings  of  the  patient  are  more  comfortable ;  he  sleeps,  and 
wakes  with  a  skin  less  hot,  and  moist,  perhaps  even  with  con- 
sideral)le  perspiration.  Headache  and  some  pain  in  the  back 
remain  ;  and  the  pulse  does  not  subside  to  the  natural  standard. 
In  scMuc  instances  it  is  little  altered.  The  stomach,  however,  is 
less  disturbed,  and  thirst  is  somewhat  less  intense. 

There  is  reason  to  believe  that  a  few  cases  of  genuine  malarial 
remittent  may,  by  prompt  treatment  during  the  hot  stage,  be 
quelled  so  as  not  to  advance  beyond  the  first  exacerbation  and 
I'cmission.  We  ascribe  their  facility  in  yielding,  chiefly,  to  a  less 
degree  of  intensity  in  the  moi-biflc  cause. 

Mostly,  in  from  six  to  twenty-four  hours,  the  patient's  discom- 
fort again  increases;  the  skin  becoming  even  hotter  than  before, 
and  quite  dry;  the  pulse  rises  to  120  in  the  minute;  thirst  is 
great,  although  sometimes  less  than  in  the  first  paroxysm ;  the 
headache  returns,  and  with  it  usually  severe  pain  in  the  back. 
The  tongue  is  now  thickly  furred,  often  with  a  yellowish  hue. 
ISTausea  and  disgust  for  food  are  again  felt,  and  in  a  large  num- 
ber of  cases  vomiting  returns;  the  stomach  rejecting  everything, 
even  cold  water.  The  stools,  when  obtained,  are  sometimes 
slate-colored  ;  but  more  often  decidedly  colored  with  bile.  Diar- 
rluea  is  uncommon,  and  is  most  apt  to  accompan}'  a  later  stage. 
Deliriuva  is  common  only  in  violent  cases;  restlessness  is  almost 
universal.  Yellowness  of  the  skin  appears  in  a  majority,  in 
various  degrees. 

The  advance  of  the  disease,  after  the  second  paroxysm,  is 


4:40  ZYMOTIC    DISEASES. 

exceedingly  various.  Tlie  periodical  character,  however,  is  main- 
tained throughout.  The  remissions  may  occur  at  any  hour — in 
moderate  cases  as  often  in  the  afternoon  as  in  the  morning ;  in 
the  protracted,  more  commonly  in  the  morning,  the  fever  lasting 
through  the  night.  Quite  frequently  a  double  tertian  type  is 
observed ;  the  exacerbation  occurring  one  day  in  the  morning, 
and  the  next  in  the  afternoon;  and  sometimes  with  different 
degrees  of  violence. 

Duration. — Favorable  cases  often  terminate  in  six  or  seven 
days  in  an  intermission,  which  in  some  becomes  a  cure  even 
without  any  antiperiodic  treatment.  The  more  violent,  espe- 
cially if  ill-managed  or  in  an  abnormal  constitution,  may  be  pro- 
tracted for  three,  four,  or  occasionally  five  or  six  weeks.  We 
should  distinguish,  however,  between  the  true  periodical  disease 
and  its  sequelcB.  The  average  duration  of  a  case  of  remittent 
fever  may  be  stated  as  about  fourteen  days. 

Dr.  Maury,  of  Memphis,  Tennessee,  asserts,'  on  the  basis  of 
large  observation,  that  the  typical  "bilious  remittent "  of  the 
Mississippi  Valley  tends  to  spontaneous  defervescence  on  the 
fifth  day,  and  may  very  often  be  terminated  by  treatment  by  the 
third  day.  He  also  describes  cases  of  "  malarial  continued  fever  " 
(not  typhoid),  with  a  self-limited  course  of  twenty-one  days.  I 
have  not  met  with  such  cases  (apart  from  typlio-malarial  fever) 
in  or  near  Philadelphia.  Nor  are  they  commonly  referred  to  by 
authors  conversant  with  diseases  of  malarial  regions. 

Complications. — These  are  usually  dependent  on  local  inflam- 
viation.  The  brain  is  perhaps  the  organ  most  frequently  affected, 
with  cerebritis  or  meningitis.  In  late  autumn,  or  other  cool 
weather,  pneumonia  is  not  uncommon.  Gastritis  and  enteritis — 
diarrhoea  and  dysentery  of  an  obstinate  character  sometimes 
occur.  "When  any  of  these  affections  exist,  they  partake  to  some 
extent  of  the  periodical  character  of  the  fever;  and  are  often 
lessened  or  removed  by  the  treatment  adapted  to  it.  In  other 
cases,  however,  they  remain  in  a  subacute  or  chronic  form;  and, 
when  death  occurs,  in  a  majority  of  instances  the  immediate 
cause  is  a  phlegmasia  of  some  organ.  Hepatitis  and  splenitis  are 
more  common  in  the  chronic  form  than  in  the  acute — and  as 
sequelae  rather  than  complications  of  the  attack. 

The  Typhoid  State. — At  any  time  after  the  fourth  or  fifth  day, 
but  particularly  near  the  end  of  the  second  week,  a  patient  suf- 
fering with  remittent  fever  may  pass  into  the  condition  desig- 
nated by  the  above  term.  Its  features  vary  somewhat ;  but  it  is 
usually  marked  as  follows  :  Pulse  120  to  140,  and  rather  deficient 
in  strength  ;  skin  harsh,  varying,  however,  with  the  slight  remis- 
sions in  dryness  and  temperature ;  face  dark  or  flushed ;  head 
hot ;  delirium,  active  more  frequently  than  comatose ;  bowels 
occasionally  affected  with  diarrhoaa,  but  as  often  costive  ;  tongue 
heavily  coated  with  sordes,  brown  or  black,  and  with  cracks  or 
fissures  across  it.  Muscular  debility  is  usually  great.  Hemor- 
rhages from  the  bowels,  lungs,  or  stomach  occasionally  increase 
the  danger. 

1  Amer.  Journal  of  Med.  Sciences,  Apvil,  1881. 


REMITTENT    F  E  V  K  It .  441 

The  chiof  causes  of  iliis  condition  arc,  1.  No<;loct  of  treatment 
in  the  early  stage,  2.  The  pveinature  and  improjier  use  of  sUm- 
ulants.  3.  The  existence  of  ccirebral  iutlannuation.  4,  In  the 
opinion  of  some,  a  particular  epidemic  tendency  to  the  typhous 
condition,  in  all  diseases,  at  certain  times,  o.  In  the  view  of 
others,  the  concurrent  existence  of  a  true  continued  fevei*,  mail- 
ing a  sort  of  hybrid.     This  last  is  possible,  at  least. 

Modes  of  Termination. — These  are,  either,  1.  Kecovery  in  a 
week  or  two  directly  from  the  febrile  state ;  2.  Conversion  into 
a  distinctly  intermiUiny  fever;  3.  Cessation  of  the  fever,  witli 
remaining  organic  inflammation  or  other  disease ;  or,  4.  Death 
during  the  progress  of  the  attack. 

The  first  of  these  occurs  sometimes  even  wlien  the  onset  has 
been  violent,  and  the  circulation  much  disturbed.  How  frequent 
its  spontaneous  occurrence  viigkt  be,  is  ditficult  to  determine 
under  ordinary  practice  in  miasmatic  regions ;  Avhere  the  first 
intermission  is  made  use  of  to  inti'oduce  antiperiodic  remedies. 
But  it  appears  that  remittent  fever  may  much  oftener  recover 
under  palliative  treatment  alone,  than  intermittent. 

The  rule,  liowever,  with  many  historians  of  the  disease  is,  to 
consider  that  favorable  cases  terminate  in  curable  intermittent. 
This  change  is  generall}'^  accompanied  by  a  discharge  from  some 
excretory  organ  or  surface,  with  propriety  termed  critical. 
Copious  perspiration ;  free  urination,  with  a  lateritious  or  other 
thick  deposit ;  the  discharge  of  abundant,  dark,  offensive  stools ; 
one  or  all  of  these  may  precede  or  accompany  the  commencing 
improvement  of  symptoms. 

A  local  intlammation,  as  pneumonia,  enteritis,  cerebritis,  or 
hepatitis,  may  survive  the  attack  which  kindled  it,  and  proceed 
as  if  it  had  been  an  original  malady. 

Where  death  occurs  within  the  first  three  weeks,  it  is  almost 
always  the  result  of  some  imfiammatory  complication.  Remit- 
tent fever  rarely  proceeds  to  a  fatal  termination,  in  the  vicinity  of 
Philadelphia,  by  mere  exhaustion  of  the  powers  of  nature.  In 
feeble  or  aged  persons,  however,  this  may  occur,  even  here  ;  and 
more  often,  in  intensely  malarial  regions. 

Sequelae. — A  slow  and  imperfect  convalescence  not  unfre- 
quently  follows  a  violent  attack  ;  attended  with  sallowness  of  the 
skin,  feeble  digestion,  muscular  and  nervous  debility.  The  only 
organic  alterations  at  all  constant  are  enlargements  of  the  liver 
and  spleen. 

Morbid  Anatomy. — Tlie  most  striking  observation  upon  this 
was  that  made  at  the  Pennsylvania  Hospital  by  Dr.  T.  Steward- 
son,  in  1841,  of  the  unusual  color  of  the  liver  ;  bronzed  without 
and  olive-green  within.  Subsequent  confirmation  of  this  has  beea 
atTorded  ;  although  Dr.  Drake,  of  Cincinnati,  failed  to  find  it  in 
his  autopsies.  The  spleen  is  almost  always  enlarged,  congested, 
and  softened.  Inflammation  of  difierent  organs  (making  fatal 
complications),  especially  of  the  brain,  lungs,  or  bowels,  may 
exhibit  its  usual  results.  Such  lesions,  however,  are  sometimes 
absent  in  the  most  malignant  cases. 

Causation.— This  has  been  considered  already,  under  the  head 
of  intermittent  fever. 


442  ZYMOTIC    DISEASES. 

Diagnosis. — Yellow  fever  has  by  some  physicians  been  regarded 
as  identical  with  remittent,  differing  mainly  in  the  grade  of  its 
violence.  The  correct  view  is,  that  they  are  specificahy  distinct 
diseases.  To  prove  this,  we  might  be  satisfied  with  the  simple 
facts  of  the  different  localization  of  the  two  fevers.  Remittent 
is  always  a  country  fever  ;  yellow  fever  almost  invariably  a  disease 
of  towns  and  the  vicinity  of  the  sea.  The  latter  is  restricted 
much  more  narrowly,  also,  in  its  actual  geographical  limits. 

But  there  are  symptomatic  differences  also  ;  which  may  be  best, 
pointed  out  after  giving  a  description  of  yellow  fever.     Among 
the  important  facts  is,  that  one  attack  of  the  latter  disease  com- 
monly gives  immunity  from  it  for  life ;  but  this  is  not  at  all  the 
case  with  remittent  fever. 

When  the  typhoid  state  supervenes,  there  may  exist  very  con- 
siderable similarity  to  the  true  typhoid  fever.  It  is  asserted  that 
a  coexistence  of  the  two  diseases  occurs.  Some  have  held  the 
opinion  that  they  are  not  specifically  different ;  but  that  typhoid 
fever  is  merely  a  protracted  remittent  of  low  form.  This  is,  how- 
ever, contradicted  clearly  by  at  least  two  facts  :  1,  the  compar- 
ative rarity  of  typhoid  fever  in  regions  where  remittent  most 
abounds  ;  and  2,  the  frequent  prevalence  of  the  typhoid  where 
remittent  fever  is  almost  unknown ;  as  in  some  of  the  N^orth- 
eastern  States. 

The  mode  of  onset  in  the  two,  moreover,  is  usually  quite 
different ;  in  typhoid,  insidious  and  almost  imperceptible  at  first ; 
in  bilious  fever,  after  a  day  or  two  of  malaise,  a  chill  abruptly 
ushers  in  the  attack.  Yomiting  is  extremely  common  in  the  one, 
quite  rare  (in  adults)  in  the  other ;  the  converse  is  true  of  diar- 
rhfjea— and  still  more  particularly  of  tympanites  and  abdominal 
tenderness.  The  deafness  and  sleeping  stupor,  and  livid  counte- 
nance of  typhoid  fever,  are  almost  entirely  peculiar.  Epistaxis, 
bronchitis,  and  the  rose-colored  eruption,  so  nearly  constant  in 
the  latter,  are  rare  in  the  typhoid  remittent ;  the  last  mentioned 
is  perhaps  never  observed.  The  yellowness  of  the  skin,  also,  and 
the  distinct  remissions,  mark  well  the  remittent  attack.  In  dis- 
section, we  find  more  gastric  and  /lepatic  change  after  bilious  fever, 
and  more  enteric  and  splenic  alteration  in  the  typhoid. 

Prognosis. — Recovery  may  be  anticipated  in  a  majority  of 
Instances.  The  writer  is  of  the  opinion  that  the  typhoid  pro- 
longation of  the  attack  ought  scarcely  ever  to  occur,  under  proper 
treatment  from  the  beginning.  Before  the  use  of  cinchona, 
remittent  was  quite  often  fatal.  Alexander  the  Great,  Emperor 
Charles  v.,  James  I.,  and  Cromwell  are  said  to  have  died  of  it. 

Favorable  signs  are,  the  earlier  occurrence  and  prolongation 
of  the  remission,  and  its  becoming  more  and  more  complete; 
moistening  and  cleaning  of  the  tongue  ;  copious  perspiration ; 
turbidness  of  the  urine,  from  increase  in  the  amount  of  its  solids  ; 
tar-like  and  offensive  stools ;  and  the  appearance  of  vesicles 
about  the  lips. 

Unfavorable,  of  course,  are  the  shortening  and  postponement 
of  the  remission,  and  its  indistinctness  ;  dryness  and  blackness 
of  the  tongue  ;  retention,  or  still  worse,  suppression  of  urine ; 
extreme  frequency,  with  weakness,  of  the  pulse  ;  hiccough  ;  and 


REMITTENT    FEVER.  443 

other  important  evidences  of  the  victory  of  disease  over  the  vital 
functions — not,  however,  pecirliar  to  the  fatal  termination  of 
this  disorder.  Tiie  supiu'vention  of  the  usual  S3-niptoms  of 
wjlammatinn  of  the  brain  is  always  very  alarmimij ;  ganlritl^  may 
occasionally  threaten  to  wear  out  the  patient's  strentrth  ;  and 
pncviiionid  is  attended  with  more  danger  when  occurring  as  a 
complication  of  fever  than  when  an  original  disease. 

Treatment.- — Tn  sections  where  it  is  very  prevalent,  this  disease 
has  been  subjected  to  a  variety  of  experimental  practice; — 
pushed— in  some  States,  with  a  boldness  and  energy  characteristic 
of  border  populations.  At  one  time,  the  early  use  of  large  doses 
of  tartar  emetic  to  produce  vomiting;  at  another,  of  calomel, 
administered  by  the  half-ounce  or  ounce  ;  and,  more  recently,  of 
quinine  with  corresponding  extravagance— have  been  the  methods 
used,  until  fairly  proved  to  be  needless  or  improper  in  violence. 

The  other  extreme,  however,  of  trusting  all  to  nature,  would 
meet  w'ith  more  signal  disappointment  in  tliis  than  in  most  other 
affections.  A  decided  treatment  is  imperatively  required  ;  what 
then  are  its  best  and  most  promising  weapons?  It  would  be 
interesting  and  instructive  to  collate  and  compare  many  author- 
ities upon  this  point ;  but  we  will  discuss  tlie  subject  in  reference, 
chiefly,  to  the  experience  of  otir  own  physicians.  It  will  be 
proper  to  state  the  valuable  testimony  of  Dr.  Drake,  to  the  mode 
of  practice  which  the  separate  judgment  and  observation  of 
medical  men  throughout  tbe  great  Western  "Valley  now  converge 
upon.  "Its  fundamental  principles,"  he  states,  "are — tbat 
autumnal  fever  is  the  product  of  a  specific  cause,  and,  therefore, 
consists  in  a  morbid  action  of  a  peculiar  kind,  requiring  a  spe- 
cific remedy  ;  that  we  possess  such  an  antidote  for  the  intermit- 
tent variety  of  the  fever  ;  and  that  we  have  only  to  abate  all  the 
causes  and  points  of  difference  between  the  two  varieties,  to  ren- 
der the  sulphate  of  quinine  as  efficacious  in  one  as  in  the  other." 

No  clearer  or  more  correct  expression  need  be  demanded,  I 
believe,  for  the  safest  and  best  plan  of  management  of  our  own 
fall  fevers.     Yet  many  voices  may  demur  at  tliis  assertion. 

Some  will  quarrel  with  the  terms  of  the  above  paragraph ; 
objecting,  and  with  some  force,  that  we  go  beyond  what  is  known 
in  pi'oclaiming  the  specific  nature  of  the  cause  of  these  fevers — 
and  still  more  in  awarding  the  name  of  antidote  to  the  sulphate 
of  quinine  or  Peruvian  bark.  But  this  is  a  verbal  question.  We 
do  know  that  malarial  fevers  are  quite  peaJior— in  locality,  in 
periodicity,  and  in  other  characters  ;  and  we  do  know  tbat  the 
salts  of  the  alkaloids  obtained  from  cinchona  control  and  arrest 
them,  as  few,  if  any,  other  remedies  can— and  with  a  power  which 
those  salts  do  not  exert  over  other  fevers. 

This  power,  however  designated  or  explained,  is  now  fully 
acknowledged  ;  the  danger  is,  in  fact,  of  its  causing  us  to  lose 
sight  of  other  important  points. 

"in  some  tropical  latitudes,  especially,  in  which  depletion  is  not 
comparatively  well  borne — and  in  districts  poisoned  with  malig- 
nant miasm — it  has  been  proved  that  quinine  is  often  required  in 
liberal  doses — is  borne  in  very  large  ones — and  acts  favorably 
without  any  of  the   preparation  of  the   system,  once   thought 


444:  ZYMOTIC    DISEASES. 

indispensable.  Tliese  facts  have  been  fully  proved.  But  the 
remaining  questions  to  be  settled  are — is  not  success  greater  in 
remitting  fever,  even  in  those  regions,  if  some  evacuant  treat- 
ment at  least  accompanies  the  use  of  the  great  remedy  ? — and — 
is  not  a  modified  treatment,  at  least  in  this  respect,  necessary  in 
less  malignant  cases,  and  difterent  climate?  The  weight  of 
evidence  favors  the  affirmative  of  both  of  these  questions/ 

It  remains,  then,  to  state  in  a  few  words,  what  is  the  plan  of 
treatment  proper  to  be  adopted.  The  physician  is  rarely  called 
until  the  febrile  condition  has  fairly  set  in.  In  a  person  of  robust 
constitution,  if  the  headache  be  very  severe,  skin  hot,  and  pulse 
full  as  well  as  rapid,  moderate  venesection  will  be  safe  at  least. 
But  it  is  much  more  common  now  to  administer  first  a  saline 
cathartic,  and  decide  on  the  grade  and  resistance  of  the  fever  by 
its  effect.  Epsom  salts  may  be  best  when  the  stomach  is  little 
disturbed,  effervescing  solution  of  citrate  of  magnesium,  or  the 
Seidlitz  powders  in  repeated  doses,  under  contrary  circumstances 
will  answer.  But  many  commence  the  treatment  with  a  dose  of 
calomel  or  blue  pill  with  rhubarb,  to  he  followed  by  a  saline  purge. 
If  obstinate  vomiting  prevail,  as  will  frequently  happen,  no  purga- 
tive will  suit  so  admirably  as  the  effervescing  solution  of  the 
citrate  of  magnesium. 

The  utility  in  many  cases  of  leeches  or  ciq^s  to  the  nucha,  and 
in  some  to  the  epigastrium,  is  clear.  As  a  refrigerant  diaphoretic, 
the  citrate  of  potassium  solution,  with  or  without  effervescence, 
may  be  given. 

Special  treatment  may  often  be  cahed  for  by  the  great  intrac- 
tability and  distress  of  stomach.  Lime-water  or  magnesia  in  small 
doses  with  ammonia  and  an  aromatic  will  frequently  reheve. 
Sinapisms  and  pediluvia  are  often  useful  adjuvants.  Ice  will 
answer  better  to  quench  thirst  than  water,  where  gastric  irri- 
tability is  great ;  otherwise  free  dilution  by  drink  is  an  advantage. 

As  soon  as  the  violence  of  systemic  excitement  has  been  moderated— 
without  waiting  for  its  entire  subjugation— if  the  pulse  has  begun 
to  subside— low eving  for  instance  from  110  or  120  to  90  or  100,  and 
the  headache  is  less  intense— i/ie  boivels  freely  moved— we  'may 
begin  with  quinine  ;  but  it  is  unnecessary  here  to  give  large  doses 
generally.  Unless  where  some  mahgnancy  is  suspected,  or  the 
remission  is  very  complete,  a  single  grain  every  two  hours  will  be 
sufficient  at  first.  Under  this  we  may  find  the  pulse  continue  to 
subside,  the  skin  to  moisten,  and  all  the  symptoms  to  improve. 
At  all  events  in  the  next  remission  the  dose  should  be  increased 
to  a  grain  every  hour — not,  as  a  general  rule,  however,  awaking 
the  patient  from  sleep.  Two  grains  every  hour  for  eighteen  hours 
is  the  freest  administration  I  have  ever  seen  to  be  necessary  in  a 
case  even  threatening  mahgnancy.  This  term,  it  need  hardly  be 
said,  is  used  to  express  the  existence  of  a  state  of  prostration 
attended  with  signs  of  visceral  congestion,  increasing  dangerously 
with  each  paroxysm  ;  reaction  being  deficient  from  an  unusual 
intensity  of  the  morbid  cause,  or  from  defect  of  constitution. 

1  Drs.  Hammond  and  Boosa  have  proved  by  experiment,  aided  by  ophthalmoscopic 
and  microscopic  examination,  that  the  use  of  quinine  produces  or  promotes  cerebral 
congestion.    See  Phil.  Med.  Times,  June  27,  1874,  p.  619. 


PERNICIOUS    FEVER.  445 

Such  cases  do  require  a  lar^e  amount  of  the  special  remedy  ;  and 
sucli  cases  are  n()doul)t  much-  more  frequent  in  warmer  Soutiiern 
States  than  here.  We  have  no  difliculty  in  believin<i;  in  the  tol- 
eration, or  even  the  propriety,  of  conmlerahl  1/  larger  doses  than 
are  here  given;  but  there  is  a  limit  even  there,  to  go  beyond 
winch  is  excess.  Many  Southern  practitioners  of  large  ex^ierience 
insist  that,  as  a  rule,  no  inrparatlon  for  quinine  is  necessary  in 
remittent  fever ;  and  some  give  larger  doses  of  quinine  in  remit- 
tent than  in  intermittent. 

After  two  or  three  days  of  constant  "  qidnhiization^''''  the  amount 
usually  may  be  diminished  to  six  or  eight  grains,  distributed 
through  tlie  day.  In  similar  quantities  it  should  be  continued 
even  through  the  period  of  convalescence. 

Tlie  treatment  of  indammatory  or  other  complications  must  of 
course  sujieradd  modilications  appropriate  to  each.  We  have 
namtid  in  the  above  sketch  all  the  Jiiain  elements  of  the  plan  which 
is  found  successful  in  such  cases  as  ordinarily  occur. 

The  existence  of  local  inflammation  in  a  genuine  malarial 
case  does  not  contraindicate  the  use  of  quinine.  Being  lit  up  by 
the  fever-poison,  and  aggravated  by  its  febrile  state,  the  treat- 
ment which  annuls  or  removes  these  will  often  lower  or  check 
the  phlegmasia.  But  this  maxim  should  be  applied  with  caution 
and  some  excei')tions,  in  cases  particularly  of  cerebral  inflamnia- 
tion  or  great  pulmonic  oppression. 

In  slow  convalescence,  with  sallowness  and  deranged  digestion, 
the  daily  administration  for  a  few  days  of  minute  Closes  of  blue 
mass  may  prove  useful.  And  to  improve  sanguification,  as  well 
as  lessen  the  danger  of  relapse  in  some  form,  the  protocarhonate 
of  iron^  in  pill  with  a  portion  of  sulphate  of  quinine,  will  make 
a  very  valuable  termination  of  the  treatment.  Arsenic  also  may 
sometimes  be  required  in  prolonged  cases. 

PERNICIOUS  FEVER. 

Synonyms. — Congestive  Fever;  Malignant  Intermittent;  Malig- 
nant Bemittent. 

Symptoms  and  Course.— Unlike  ordinary  intermittent,  a  par- 
oxysm of  the  pernicious  form  may  commence  either  in  the  day 
or  at  night.  At  first,  however,  in  many  cases  it  begins  like  the 
common  type  of  chills  and  fever,  or  remittent  fever;  after  one, 
two,  or  three  days  becoming  more  alarming. 

Then  the  skin  grows  lividly  pale,  shrunken,  and  sometimes 
clannny  with  cold  sweat ;  the  countenance  anxious  ;  the  tongue 
either  pale,  furred,  or  natural ;  in  the  worst  cases  it  is  cold. 
Thirst  is  intense,  with  a  sense  of  internal  heat.  The  stomach  is 
excessively  irritable,  and  vomiting  very  common,  of  mucus  or  a 
muco-serous  or  even  bloody  fluid.  The  bowels  are  in  most  cases 
loose,  the  dejections  resembling  bloody  water.  The  pulse  is 
usually  small,  weak,  and  rapid  or  irregular ;  in  a  few  instances 
corded.  The  respiration  is  interrupted  and  sighing,  with  a  sense 
of  oppression. 

Eestlessness  is  usual ;  Init  the  mental  faculties  in  many  cases 
are  clear.  There  are,  however,  many  others  in  which  the  weight 
38 


446  ZYMOTIC    DISEASES. 

of  the  attack  falls  on  the  brain.  Then  the  early  symptoms  are 
drowsiness  and  hesitation  of  speech.  Stupor  marks  the  depth 
of  the  paroxysm.  The  breathing  may  be  stertorous,  or  tetanic 
spasms  may  occur.  The  pulse  in  the  former  case  may  be  slower 
than  in  the  other  form  described ;  but  it  is  still  weak,  and 
even  if  the  head  be  somewhat  warm,  the  vessels  of  the  neck 
and  temples  are  not  apt  to  be  swollen,  and  the  skin  of  the  body 
is  cold. 

Partial,  or,  it  may  be,  complete  reaction  in  most  instances 
follows  alter  three  or  four  hours  of  the  above  symptoms,  though 
death  may  instead  take  place  in  the  collapse.  Again  the  fever 
may  intermit  or  remit,  and  at  the  same,  or  an  earlier  hour,  the 
next  day  another  paroxysm  occurs.  This  is  more  dangerous 
than  the  first.  If  a  third  be  allowed  to  take  place,  it  is  generally 
fatal. 

Morbid  Anatomy. — Congestion  of  the  brain,  liver,  spleen,  and 
alimentary  mucous  membranes  is  so  prominent  an  autopsic  phe- 
nomenon as,  with  the  symptomatic  appearances  of  the  same,  to 
have  seemed  to  justify  the  older  and  more  common  name  of  the 
disease.  We  have  good  reason  to  believe,  however,  that  the 
toxiBmic  impression  of  malaria,  and  its  effects  upon  the  nerve- 
centres  (either  of  organic  or  of  animal  life),  are  primary,  and  the 
congestion  secondary. 

Diagnosis. — The  intensiti/  of  the  symptoms,  and  the  general 
prostration  or  coma,  will  distinguish  this  from  ordinary  intermit- 
tent or  remittent.  Tbe  condition  of  a  severe  case  is  not  unlike 
an  attack  of  epidemic  cholera :  but  the  discharges  are  difi'erent, 
and  the  locality  and  season,  unless  in  the  presence  of  that  epi- 
demic, will  point  directly  to  malarial  causation. 

As  pernicious  fever  is  rare  in  the  latitude  of  Philadelphia 
(much  more  common  farther  south,  especially  near  the  rice  plan- 
tations of  the  Southern  States),  I  have  seen  but  few  cases  of  it. 
One  of  them  gave  me  difficulty  in  diagnosticating  it  from  apo- 
plectic coma,  as  it  occurred  in  a  lady  over  sixty  years  of  age. 
The  distinctness  of  the  cold  stage  at  the  beginning  of  the  attack, 
and  my  knowledge  of  the  patient's  history,  with  the  possibility  of 
exposure  to  malaria,  led  me  to  prescribe  quinine  with  some  free- 
dom ;  and  the  result  established  the  nature  of  the  case,  as  entire 
recovery  followed. 

Prognosis. ^Without  appropriate  treatment  a  large  majority 
of  cases  would  be  fatal.  There  are  few  diseases  displaying  a 
greater  tendency  to  death.  Under  cinch onism  and  other  proper 
management  not  more  than  one  in  eight,  probably,  will  die. 

Treatment. — As  above  implied,  quinine  is  our  great  reliance  in 
this  disease.  Larger  doses  are  required  than  in  ordinary  inter- 
mittent. While  opinions  differ,  the  best  evidence  I  can  obtain 
convinces  me  that  from  thirty  to  sixty  grains  of  quinine  in 
twenty-four  hours  will  do  all  that  the  remedy  can  do ;  more  will 
be  wasteful  and  dangerous. 

But  in  most  cases  other  means  must  be  employed,  sometimes 
before  quinine  can  be  kept  upon  the  stomach  to  promote  reac- 
tion. External  stimulation  is  foremost  ainong  these  means. 
Direct  heat  may  be  applied  by  hot-water  bottles  or  tins,  hot 


PROPHYLAXIS   OF   MALARIAL    FEVPMt.  447 

bricks,  bap;s  of  hot  salt  or  sand  laid  aloncj  tho  spine,  or  by  the 
hot  bath.  Thirst  should  at  tJie  same  time  be  quenched  by  cold 
water,  or,  if  the  sense  of  heat  be  yreat  and  vomitint?  occur,  with 
ice.  Mustard  plasters  may  be  placed  upon  the  spine,  epi<j;as- 
trium,  or  limbs;  or  the  extremities  may  be  rubbed  with  brandy 
and  red  pepper. 

The  opposite  of  this  plan  is  preferred  by  some  upon  asserted 
favorable  experience,  viz;.,  the  pouring  or  dashing  of  cold  water 
quickly  upon  the  naked  body.  Extensive  dry  cupping  along  the 
spine  is  reconmunided  by  others.  From  what  I  have  seen  of  the 
good  effects  of  dry  cupping  along  the  spine  in  the  collapse  of 
cholei-a,  I  should  have  some  confidence  in  it  for  this  analogous 
condition. 

Internal  stimulation  is  demanded  under  the  same  circum- 
stances. Most  used  have  been  camphor,  opium,  ether,  oil  of 
turpentine,  ammonia,  and  capsicum  [F.  163],  besides  wine  and 
brandy  or  whisky.  The  best  testimony  is  in  favor  of  camphor 
and  opium,  with  quinine  [F.  164],  in  moderate  doses,  every  half 
hour  during  the  chill,  when  no  comatose  symptoms  are  present. 
If  these  exist,  oil  of  turpentine,  by  the  mouth  or  rectum,  has  its 
decided  advocates. 

Calomel  has  1)een  largely  used  in  the  same  cases.  My  experi- 
ence in  pernicious  fever  has  not  atforded  me  data  for  an  opinion 
about  it;  but  I  respect  the  evidence  of  those  who  think  they 
have  seen  it  to  be  beneficial. 

Alcoholic  stimulants  seem  to  be  indicated  in  the  collapse.  A 
tablespoonful  of  bnuidj'  or  whisky  every  half  hour  or  hour  vmtil 
irjiction  occurs  would  be  suitable  in  very  feeble  cases.  Yet  the 
abstraction  of  blood  was  formerly  a  not  uncommon  remedy  in  the 
same  condition,  and  was  certainly  sometimes  followed  by  recovery. 

After  reaction  has  been  established,  even  imperfectly,  and  an 
intermission  or  remission  exists,  the  "sheet  anchor"  is  quinine. 
Then,  if  the  stomach  bears  it,  five  to  ten  grains  may  be  given 
every  two  or  three  hours,  until  cinchonism  is  fully  established. 
When  the  quinine  is  rejected  by  the  stomach,  hypodermic  injec- 
tion may  be  resorted  to.  Ten  grains  or  more  may  be  introduced 
at  once  in  solution  in  water,  with  just  sulphuric  acid  enough  to 
dissolve  it  perfectly. 

In  the  cerebral  cases  calomel  is  particularly  appropriate.  A 
blister  to  the  nucha  may  be  recommended  in  the  same  cases. 
Purgatives  also  are  apt  to  be  required  ;  and,  if  the  heat  of  the 
head  be  great,  iced  water  may  be  kept  applied  over  it,  while  hot 
bottles  or  sinapisms  are  put  in  contact  with  the  legs  or  feet. 

When  the  critical  period  in  pernicious  fever  has  passed,  it  will 
need  treatment  like  an  ordinary  case  of  intermittent  or  remittent, 
according  to  the  type  which  it  assumes.  A  modification  of  this 
affection,  sometimes  called  "winter  fever"  in  the  South,  has  been 
already  considered  under  the  head  of  typhoid  pneumonia. 

PEOPHYLAXIS   OF  MALARIAL  FEVER. 

When  avoidance  of  malarial  localities  is  impossible,  during  the 
season  of  fevers  (from  July  until  frost  in  some  parts  of  the  United 


448  ZYMOTIC    DISEASES. 

States,  from  the  first  of  Aug-ust  at  least  in  this  vicinity),  exposure 
sliould  be  especially  guarded  against  at  night,  and  about  the  times 
of  sunrise  and  sunset.  Residents  in  such  places  should  have  a 
fire  burning  to  dry  the  house  whenever  the  weather  is  damp, 
whatever  the  season.  Going  into  a  marsh)'-  place  with  an  empty 
stomach  is  very  exposing.  Long  ago,  it  was  believed  by  many 
that  the  growth  of  the  sunflower  (helianthus  annuus)  is  preventive 
of  malaria.  Lately  this  opinion  has  been  revived  in  the  !N'ether- 
lands.  Dr.  Salisbury,  upon  his  theory  of  the  palmellar  (minute 
vegetative)  origin  of  raarsh-miasm,  advises  covering  the  swampy 
ground  with  lime.     Sometimes  it  would  be  cheaper  to  drain  it. 

Quinine  may  be  used  as  a  prophylactic.  Livingstone  and  Du 
Chaillu  have  tried  it  in  Africa  ;  the  former  too  sparingly  to  suc- 
ceed perfect]}^,  the  latter  with  better  results.  In  the  United 
States  army  during  the  civil  war  it  was  fouud  useful.  Six  grains 
daily  is  the  least  amount  to  be  relied  upon. 

TYPHO-MALARIAL  FEVEE. 

Although  this,  having  had  its  principal  origin  in  the  circum- 
stances of  the  late  war,  may  be  now  almost  entirely  a  matter  of 
past  history,  it  yet  requires  a  place  among  recognized  diseases. 
It  was,  during  the  war,  the  result  of  a  threefold  causation ;  the 
elements  of  which  were  malarial  ivfluence,  crowd-poison,  and  scor- 
hutic  taint.  According  to  the  predominance  of  one  or  the  other 
of  these,  its  character  in  different  cases  was  determined.  During 
service  in  a  United  States  General  Hospital  in  the  summer  and 
fall  of  1862,  as  well  as  in  the  Episcopal  Hospital,  I  saw  many 
cases  of  this,  called,  from  its  local  origination,  the  Chickahominy 
fever.^  Of  the  form  in  which  the  malarial  element  predominated, 
the  somewhat  abrupt  commencement,  gastric  disturbance,  and 
icteroid  skin  and  tongue,  with  remissions,  tolerably  distinct,  were 
predominant  features.  The  lenticular  spots  of  typhoid  fever,  and 
the  sudamina  and  tympanites  were  often  wanting  together. 

A  slower  onset,  less  distinct  remissions,  more  cerebral  disturb- 
ance and  diarrhoea,  with  epistaxis  and  bronchitis  sometimes,  but 
with  both  less  constantly  than  in  civil  life,  marked  the  predom- 
inance of  the  typhoid  pathogenetic  element.  Deafness,  under 
ray  observation,  was  less  frequent  than  in  civil  life,  but  was  some- 
times very  well  marked.  The  aspect  of  the  countenance,  and 
the  character  of  the  somnolence  and  delirium,  were  precisely 
the  same  as  in  ordinary  typhoid  fever. 

The  scorbutic  complication  was  recognizable,  in  the  third  group 
of  cases,  by  the  peculiar  mental  and  bodily  prostration  which 
preceded  and  followed  the  disease— the  remarkable  irritability 
of  the  heart,  the  state  of  the  gums,  tendency  to  hemorrhage, 
discolorations  and  petechise,  pallid,  large,  and  smooth  tongue,  and 
extremely  protracted  convalescence. 

Morbid  Anatomy. — Most  important  was  the  intestinal  lesion, 


1  A  full  account  of  all  varieties  of  typho-malarial  fever  is  given  in  Dr.  J.  J.  Wood- 
ward's "Camp  Diseases  of  the  United  States  Army." 


YELLOW     FEVER.  449 

similar  to  that  of  typhoid  or  "enteric"  fever,  though  not  iden- 
tical.    Th(!  following  account'of  this  is  from  Dr.  Woodward.' 

"  In  tlu>,  earlier  stages  there  is  little  to  distinguish  the  intes- 
tinal lesion  from  the  corresponding  process  of  ordinary  enteric 
fever,  except  perhaps  tiic;  great  tendency  to  the  deposit  of  black 
pigment  in  the  enlarged  follicles.  In  the  latter  stages,  certain 
peculiarities  are  often  distinctive  enough  to  enable  the  anatomist 
to  recognize  typho-malarial  fever  by  the  post-mortem  appearances 
alone.  The  tumefaction  in  t3q)ho-malarial  fever  rises  very  grad- 
ually from  the  surrounding  mucous  memltrane,  and  attains  a 
moderate  degree  of  thickness  (three  to  six  lines)  on  the  edges  of 
the  ulcer.  In  this  it  diilers  materially  from  the  ordinary  typhoid 
ulcer,  in  which  the  enlarged  patch  rises  abruptly  from  the  mucous 
membrane  in  such  a  way  that  the  summit  is  often  larger  than  the 
constricted  base,  giving  rise  to  the  comparison  made  by  Roki- 
tansky,  who  likens  the  shape  of  the  tumefaction  to  that  of  fiat 
sessile  fungi.  The  umbilicated  depression,  so  frequent  in  the 
ordinary  typhoid  patches  prior  to  ulceration,  has  never  been 
observed  in  typho-malarial  fever.  The  ulcer  itself  presents 
ragged,  irregular  edges,  which  are  often  extensively  undermined 
in  consequence  of  the  erosion  extending  more  widely  in  the 
submucous  connective  tissue  than  in  the  glandular  tissue  of  the 
mucous  membrane.  This  characteristic  undermining  of  the 
edges  is  much  more  extensive  in  these  than  in  ordinary  typhous 
ulcers." 

Pathology. — Doubting  not  at  all  the  presence  of  the  malarial 
element,  the  question  occurs,  was  the  modifying  "febrile"  cause 
of  the  tj/phnus  or  of  the  ti/plioid  character'?  Granting,  that  is,  that 
these  are  pathogenetically  distinct,  we  should  expect  that  the 
typhous  or  "crowd-poison  "  element  must  result  from  the  circum- 
stances, as  from  those  which  have  made  typhus  or  "camp  fever  " 
the  scourge  of  armies  in  Europe.  Only,  against  this,  we  have 
the  local  lesion  of  the  glands  of  Peyer  and  mucous  membrane 
of  the  bowels,  recalling  enteric  or  typhoid  fever. 

But — as,  wdiere  typho-malarial  fever  occurred,  causes  of  intesti- 
nal irritation  (bad  water,  deficient  food,  etc.)  w^ere  present — I  am 
not  satisfied  that  such  an  appearance  (not,  as  we  have  seen,  iden- 
tiad  with  that  of  typhoid  fever)  should  exclude  the  idea  of  the 
zymotic  action  being  that  of  the  tyjihous  cause.  In  that  opinion, 
as  a  probability,  not,  of  course,  now  demonstrable,  I  rest. 

Treatment. — From  the  above  view  of  the  hybrid  and  threefold 
nature  of  the  disease,  came  its  rational  treatment.  More  qidnine 
than  in  typhus,  more  alcohol  than  in  remittent,  more  fresh  vcyetable 
food  and  fruit  than  in  either.  Experience  justified  this  plan.  In 
our  hospitals  in  Philadelphia,  few  died  from  fever  who  were  not 
moribund  on  their  arrival  from  the  seat  of  war. 

YELLOW  FEVER. 

Only  certain  locahties  have  ever  been  subject  to  this  disease  ; 
and  of  those,  most  have  had  it  but  occasionally.     It  existed  as 

1  Op.  cit.,  pp.  102-3. 

38*  2D 


450  ZYMOTIC    DISEASES. 

far  north  as  Boston  in  1693  ;  very  rarely  since,  in  any  similar 
latitude.  In  New  York,  it  occurred  in  1068,  1702,  1743,  1795, 
1803,  and  1822  ;  first  in  New  Orleans,  1769.  In  Philadelphia,  it 
first  appeared  in  1699  ;  then  in  1741,  1747,  1762,  1793,  1794,  1819, 
1820,  1853,  1854,  and  1855 ;  the  last  visitations  being  to  a  very 
moderate  extent.  The  worst  epidemic  in  New  Orleans,  where  it 
has  been  frequent  (almost  annual),  was  in  1853.  Sanitary  meas- 
ures, under  G-eneral  Butler's  military  rule,  in  1862,  appeared  to 
avert  it,  in  that  city,  amid  circumstances  which  might  have  been 
expected  to  promote  it.  A  very  severe  visitation  of  yellow  fever 
occurred  at  Norfolk  and  Portsmouth,  Virginia,  in  1855.  A  still 
more  destructive  one  devastated  Memphis,  Tenn.,  and  Shreve- 
port.  La.,  in  the  summer  of  18'^3.  In  1878  many  places  in  the 
South  suffered  great  mortality  from  it.  In  1879,  Memphis  was 
almost  ruined  by  it.  Wise  and  liberal  sanitary  improvements, 
however,  give  a  reasonable  hope  of  its  future  exemption  from 
such  devastation,  which  has  been  strongly  encouraged  by  its 
entire  freedom  from  yellow  fever  in  1880.^ 

All  the  places  which  it  has  ever  visited  are  upon  the  borders  of 
the  Atlantic  Ocean,  or  its  tributary  waters,  the  Gulf  of  Mexico, 
and  the  Mediterranean  Sea.  Although  with  like  climatic  condi- 
tions, it  is  common  in  the  West  Indies  and  West  Africa,  but 
unknown  in  the  East  Indies,  the  eastern  shores  of  Africa,  and 
the  Pacific  .coast  of  America. 

Symptoms  and  Course. — With  an  abrupt  beginning,  or  an  indis- 
tinct cold  stage,  and  pains  in  the  back  or  limbs,  commencing  often 
in  the  night,  a  febrile  stage  occurs,  of  long  average  duration ; 
sometimes  two  or  three  days  without  remission.  Violent  cases 
have  it  shorter  ;  it  may  last  only  a  few  hours. 

The  skin,  at  this  period,  is  hot  and  dry.  Thirst  is  extreme, 
the  tongue  is  generally  furred.  Nausea  and  vomiting  are  common 
on  the  second  day,  with  great  epigastric  tenderness.  The  bowels 
are  costive ;  if  discharges  occur  they  are  very  offensive. 

A  flush  of  the  forehead,  with  a  fiery  look  of  the  eyes,  is  charac- 
teristic. Delirium  is  frequently  present.  Violent  headache  is 
nearly  universal. 

The  stage  which  follows  this  pyrexia  is  a  sort  of  remission  or 
intermission.  All  the  symptoms  abate  except  the  epigastric  ten- 
derness. The  flush  of  the  face  and  other  portions  of  the  skin  is 
succeeded  by  yellowness,  vyhich  grows  deeper  as  the  disease 
advances.  The  pulse  becomes  slower,  heat  lessens,  respiration 
becomes  natural  in  frequency,  the  patient  sits  up  and  feels  better. 
This  state  of  things  lasts  for  a  variable  time,  averaging  about 
twelve  hours. 

Sometimes  convalescence  now  takes  place.  Much  more  often 
a  third  stage  succeeds,  of  prostration  or  collapse.  Muscular  debil- 

1  The  following  places  (recorded  for  possible  future  reference)  in  the  Southern  States 
■were  visited  by  the  great  yellow  fever  epidemic  of  1878:  Louisiana,  Ngw  Orleans, 
Plaquemine,  Baton  Rouge,  "Morgan  City,  Hudson,  Port  Hudson ;  Alabama,  Mobile, 
Decatur;  Mississippi,  Vickstiurg,  "Holly  Springs,  Canton,  Ocean  Springs,  Pass  Christian, 
Water  Valley,  Port  Gibson,  Grenada,  Bay  St.  Louis,  Friar's  Point,  Mississippi  City, 
Spring  Hill,  Crystal  Springs,  Biloxi,  Greenville,  Hernando ;  Tennessee,  Memphis,  Browns- 
ville, Chattanooga,  German  town,  Paris,  Grand  Junction;  Kentucky,  Louisville,  Hick- 
man ;  Missouri,  St.  Louis ;  Illinois,  Cairo. 


Y  E  I.  T.  O  W     FEVER. 


451 


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ity  becomes  great ;  (ho  pulse  is  rapid,  irregular,  and  compressible  ; 
the  capillarycirculation  sluggigji ;  the  skin  deep  yellow  or  bronzed  ; 
the    tongue    brown ;    the 

stomach   excessively  irri-  Fig.  120. 

tal)le.  It  is  at  this  time 
that  the  hlavk  vomit  oc- 
curs, which  is  pathog- 
nomonic of  this  fever. 
Hemorrhages  may  also 
occur  from  the  mouth, 
throat,  or  bowels.  The 
mind  grows  apathetic,  or 
low  muttering  delirium 
exists.  In  bad  cases,  which 
are  many,  hiccough,  clam- 
my sweats,  convulsions, 
and  involuntary  dis- 
charges precede  dissolu- 
tion. Death  most  fre- 
quently takes  place  on  the  Temperature  in  Yellow  Fever.  Recovery. 
fourth,  fifth,  or  sixth  day. 

"When  there  is  reaction  from  the  collapse,  there  follows  a  sec- 
ondary fever,  of  very  variable  duration,  which  may  terminate  in 
a  tedious  convalescence,  an  almost  equally  prolonged  typhoid 
condition,  or  death  by  exhaustion. 

Black  Vomit. — This  has  been  found,  upon  chemical  and  micro- 
scopical examination,  to  consist  essentially  of  blood,  altered  by 
action  of  the  fluids  of  the  stomach.  It  is  usually  acid  to  test- 
paper. 

The  urine,  in  yellow  fever,  Is  scanty  and  high-colored  at  the 
beginning,  and  especially  deficient  in  amount  from  the  third  to 
the  fifth  day.  About  the  fourth  day  it  becomes  cloudy  and 
dei)osits  a  sediment.  Granular  tube-casts  from  the  kidneys  may 
be  discovered  in  it  on  the  fifth  day.  Blood  and  bile  also  may 
appear  in  it ;  as  well  as  large  amounts  of  creatin  or  creatinin. 
Urea  is  apt  to  be  below  the  normal  quantity. 

Morbid  Anatomy. — Congestion  of  the  brain  is  common  ;  inflam- 
mation of  the  stomach  also  is  usual.  The  liver  is  most  frequently 
dry,  pale  yellow,  and  antemic  ;  but  occasionally  it  is  engorged. 
Fatty  accumulation  in  the  liver  has  been  repeatedly  observed  ; 
and  exudation  into  its  substance  is  asserted.  The  spleen  is  little 
altered  ;  the  kidneys  are  always  congested.  Crevaux,  Guechet, 
and  Gama  Lobo  have  especially  studied  the  morbid  anatomy  of 
yellow  fever.  During  the  year  1879,  elaborate  investigation  was 
made  concerning  it,  microscopically  as  well  as  macroscopically, 
b}^  Drs.  Sternberg,  II.  D.  Schmidt,  Guiteras,  Satterthwaite,  and 
Woodward.^  Not  only  did  they  confirm  the  previous  observa- 
tions of  Alonzo  Clark,  T.  H.  Bache,  Leidy,  and  Riddell,  of  fatty 
degeneration  of  the  liver,  but  they  found  evidences  of  a  similar 
change  also  in  the  brain,  sympathetic  ganglia,  stomach,  and  kid- 
neys.    Probably,  in  each  of  these  organs,  a  stage  of  hypera^mia 


I  Supplement  No.  4,  National  Health  Bulletin,  1880. 


462  ZYMOTIC    DISEASES. 

precedes  the  fatty  alteration.  Indeed  congestion  of  most  of  the 
internal  organs  was  found  by  Dr.  Schmidt  in  a  number  of  in- 
stances. Dr.  Sternberg  noticed,  besides  crenation  of  the  red  cor- 
puscles, a  marked  increase  of  highly  refractive  granules  in  the 
white  corpuscles  of  the  blood,  taken  during  life  from  yellow  fever 
patients.  These  he  interpreted  as  showing  a  commencing  fatty 
degeneration  of  the  corpuscles.  Drs.  Joseph  Jones  and  J.  G. 
liichardson  assert  the  observation  of  numbers  of  bacteria  in  the 
blood,  urine,  kidneys,  etc.,  of  cases  of  yellow  fever.  Drs.  Schmidt 
and  Sternberg  did  not  find  any  such  forms,  except  when  the 
materials  examined  had  been  kept  for  some  time  after  death. 

Diagnosis. — The  only  doubt  likely  to  be  entertained  is  as  to  its 
discrimination  from  bilious  remittent  fever.  As  already  remarked, 
the  latter  is  a  disease  of  the  country,  in  any  warm  quarter  of  the 
globe.  Yellow  fever  is  restricted  geographically,  and  is  seldom 
mSt  with  except  in  towns  and  near  the  sea  or  large  rivers  empty- 
ing into  it.  The  order  of  stages  in  the  two  diseases  is  different ; 
remittent  never  has  a  pyrexia  lasting  over  twenty -four  hours 
without  mitigation..  There  is  more  epigastric  tenderness  in  yel- 
low fever.  The  jaundiced  hue  of  the  skin  is  more  commonly  met 
with,  and  more  decided,  in  that  disease.  Albuminuria  and 
hemorrhages  are  usual  in  yellow  fever  ;  not  so  in  remittent.  The 
black  vomit,  when  it  occurs,  is  decisive.  Possibly,  even  probably, 
in  a  few  localities,  the  combined  causation  of  the  two  fevers  may 
produce  hybridity  between  them.  Immunity  for  a  lifetime  after 
one  attack,  is  common  with  yellow  fever ;  not  at  all  with  remit- 
tent. 

Prognosis. — This  is  a  very  dangerous  disease,  the  deaths  from 
it  averaging  about  one  for  three  cases.  A  long  and  moderate 
febrile  paroxysm,  without  excessive  irritation  of  the  stomach, 
is  favorable.  So  is  the  occurrence  of  secondary  fever  instead  of 
collapse  after  the  remission.  Black  vomit  is  almost  (not  quite) 
always  a  fatal  sign ;  suppression  of  urine  is  equally  unfavorable. 
Some  instances  of  the  disease  are  called  walking  cases,  because 
their  early  symptoms  are  slight,  only  the  countenance  and  pulse 
betraying  the  danger,  until  near  the  end. 

Pathology  and  Causation. — There  seems  no  room  for  doubt 
that  yellow  fever  is  a  zymotic  disease  whose  cause  is  generated 
only  under  certain  local  conditions.  That  cause  must  be  itself 
material ;  and,  probahhj^  being  slow  and  limited  in  transporta- 
tion, it  is  a  microscopic  vegetation. 

The  local  conditions  observed  are :  1.  Continued  high  heat ; 
about  8U°  for  one  or  two  months.  2.  Excess  of  moisture  in  the 
air ;  a  high  dew-point.^  3.  Vicinity  to  the  sea,  or  to  a  large  river 
emptying  into  the  sea.  4.  Organic,  especially  vegetable,  matter 
in  a  state  of  decomposition.  This  is  furnished  not  only  by  the 
offal,  etc.,  of  cities,  but  by  decaying  wharves  and  causeways  (as 
at  Norfolk,  Ya.),  and  by  newly  upturned  earth.  Mobile  was 
almost  relieved  of  danger  from  yellow  fever  by  paving  the  streets 
of  the  city  with  oyster  shells. 

1  This  is  not  witliout  exception.  Matthew  Carey  relates  that  at  Philadelphia,  in 
1793,  the  months  of  August  and  September,  and  much  of  October,  were  remarkably  dry 
and  sultry.  , 


YELT^OW    FEVER.  453 

But  it  is  very  remarkfiblo,  as  already  stated,  that  certain  quar- 
ters, only,  of  the  <2;l()l>e  ever  have  this  disease,  though  presenting 
all  the  above  con(litions.  It  never  visits  the  Paeilic  coasts  either 
of  America'  or  Asia.  Canton,  Calcutta,  Bombay,  Alexandria, 
Constantinople,  and  Athens,  have  never  seen  it.  Nor  have  any 
of  the  interior  cities  of  either  continent.  It  visits  often  the 
tropical  islands  of  the  Atlantic,  the  north  coast  of  South  Amer- 
ica, Vera  Cruz,  the  West  India  Islands,  New  Orleans,  Savannah, 
Charleston  ;  nccdsinnalh/  the  western  coast  of  Africa,  llio  Janeiro, 
Buenos  Ayres,''  Bermuda,  Natchez,  Mobile,  and  other  United 
States  ports  and  cities,  as  far  north  as  Boston  and  Providence  ; 
also  Gibraltar,  Marseilles,  and  other  places  on  the  Mediterranean, 
as  far  as  Sicily.  It  was  very  destructive  in  1870  at  Barcelona, 
in  Sj)ain. 

The  contcujiousncss  of  yellow  fever,  from  person  to  person,  is 
disproved  by  the  immense  preponderance  of  facts  incompatible 
with  it.  A  very  few  apparent  examples  of  transmission  by  indi- 
viduals, if  admitted  to  have  occurred,  are  otherwise  explained. 
Trdnsportation  hy  sJiiiJS  is  admitted,  because  a  ship  may  carry  a 
section,  as  it  were,  of  a  locality,  with  all  its  conditions  and 
atmosphere.  But,  then,  the  port  to  which  the  ship  goes  must 
have  all  the  conditions  rife  for  the  propagation  of  the  disease, 
or  its  "germs  "  will  not  be  maintained  so  as  to  cause  an  epidemic.* 
Naval  surgeons  of  experience  assert  that  only  a  foul  ship  can 
carry  yellow  fever.  Moi'e  will  be  said  of  this  under  the  head  of 
Prophylaxis. 

Treatment. — No  specific  has  been  found  for  j-ellow  fever,  and 
no  abortive  treatment.  All  kinds  of  remedies  have  been  tried 
for  this  in  vain ;  especially  bleeding,  calomel,  and  quinine.  I  say 
in  vain  as  to  cutting  it  short ;  but  in  palliating  and  conducting  it 
through  its  stages  with  safety,  those  and  other  remedies  may  be 
of  use.  Bleeding  is  suggested  by  the  relief  often  attending  spon- 
taneous hemorrhages  in  its  course ;  but,  as  in  other  malignant 
affections,  the  cases  for  it  must  be  well  selected,  the  time  early, 
and  the  amount  moderate.  Much  the  greater  number  will  gain 
only  by  the  application  of  leeches  or  cups  to  the  epigastrium  or 
back  of  the  neck.' 

Many  authorities  approve  of  the  use  of  calomel  as  a  cholagogue 
cathartic,  at  least  in  a  single  dose  (say  of  three  or  five  grains), 
followed  by  a  saline  laxative,  as  citrate  of  magnesium,  near  the 
beginning  of  the  attack.  All  the  result  of  the  use  of  quinine, 
of  which  I  feel  sure,  is,  that  it  is  not  likely  to  do  good  at  any  early 
stage,  but  only  when  prostration  begins  to  appear ;  and  then  in 

1  A  single  instance  of  its  occurrence  on  shipboard  off  the  west  coast  of  Soiith  Amer- 
ica has  been  asserted.    If  so,  no  doubt  it  was  a  case  of  limited  transporhuion  by  a  vessel. 

2  At  Buenos  Ayres,  in  1871,  the  mortality  from  yellow  fever  reached,  for  a  time,  over 
700  daily. 

3  On  the  whole  subject  of  yellow  fever,  see  La  Eoche's  exhaustive  treatise. 

■»  The  followinc;  may  be  regarded  as  a  curiosity  of  medical  history.  Matthew  Carey, 
in  his  account  of  the  yellow  fever  of  1793  in  Philadelphia,  says:  "The  efficacy  of  bleed- 
ing in  all  cases  not  attended  with  putridity  was  great.  The  quantity  of  blood  taken 
was,  in  many  cases,  astonishing.  I)r.  Griffiths  was  bled  seven  times  in  five  days,  and 
asi-ribes  his  recovery  principally  to  that  operation.  Dr.  Jlease,  in  five  days,  lost  seventy- 
two  ounces  of  blood,  by  which  he  was  recovered  when  at  the  lowest  stage  of  the  dis- 
order. Many  others  were  bled  still  more,  and  are  now  as  well  as  ever  they  were."— 
A  Short  Account,  etc.,  p.  25. 


454  ZYMOTIC    DISEASES. 

tonic  or  supporting,  not  cinchonizing,  doses.  It  is  undoubtedly 
of  service  during  convalescence. 

Attention  to  the  stomach  is  demanded  by  urgent  symptoms. 
Ice,  by  the  mouth,  is  refreshing  and  useful ;  so  is  mineral  water, 
or  iced  champagne,  a  little  and  often  ;  lime-vi^ater,  charcoal  water, 
and  hot  coifee  have  sometimes  done  service  in  arresting  vomiting. 
A  mustard  or  spice  plaster  over  the  epigastrium,  or  a  blister 
dressed  with  acetate  of  morphia,  may  have  an  important  effect 
upon  the  same  symptom. 

During  the  hot  stage,  cold  sponging  to  the  face,  body,  and 
limbs  will  sometimes  promote  perspiration  better  than  any  other 
measure.  Enemata  of  cold  water  (with  care  not  to  chill  too 
powerfully)  have  been  used  for  the  same  end.  Dr.  Miller, 
IJ.S.ISr.,  lias  found  the  hot  bath  (114°  Fahr.)  especially  service- 
able. 

On  the  other  hand,  Dr.  F.  Peyre  Porcher,^  of  Charleston,  South 
Carolina,  urges  the  application  of  ice-cold  water  to  the  head, 
hands,  and  arms,  as  long  as  there  is  a  continuance  of  abnormal 
heat. 

In  the  collapse,  stimulation  will  be  needed,  by  wine,  brandy, 
or  whisky,  etc.,  along  with  concentrated  liquid  food,  in  small 
amounts  at  short  intervals.  When  the  stomach  is  very  irritable, 
nourishment  may  be  given  by  the  rectum. 

Experiments  with  antiseptic  substances,  as  chlorine,  the  sul- 
phites, and  carbolic  acid,  already  made  with  other  affections 
analogous  to  yellow  fever,  may  be  properly  tried  with  it  also. 
Dr.  Eiddes,  of  Jamaica,  reports  very  favorably  of  the  sulphites. 

Prophylaxis. — Besides  what  has  been  said,  the  following  state- 
ments will  indicate  the  principles  of  prevention  of  this  disorder: — 

1.  The  infection  of  yellow  fever  is  rarely  diffused  over  regions 
of  great  extent ;  mostly  its  immediate  limits  may  be  measured  by 
fractions  of  a  square  mile. 

2.  The  removal  of  the  inhabitants  of  an  infected  spot  will 
inevitably  put  an  end  to  an  endemic  or  epidemic  of  it. 

3.  Sanitary  police  may  effectually  prevent  it  (as  at  New  Orleans 
in  1862  and  1873),  and  will  mitigate  it  even  after  its  outbreak. 
The  immunity  of  Nashville  in  1879,  under  good  sanitation,  but 
without  quarantine,  as  reported  by  Dr.  J.  Berrien  Lindsley,  and 
the  complete  absence  of  yellow  fever  at  Memphis,  following  great 
sanitary  improvements,  in  1880,  are  telling  facts. 

4.  The  material  cause  of  yellow  fever  is  never  generated  or 
multiplied  in  the  bodies  of  those  having  the  disease ;  they  may 
be  taken  anywhere  without  fear  of  communicating  it,  any  more 
than  well  persons.^ 

5.  The  germs  of  the  disease  are  extremely  seldom,  if  ever 
transported  hyfomites;  i.  e.,  clothing,  bedding,  merchandise,  etc. 
If  they  exist  in  any  such  material,  tliey  are  certainly  destructible 
by  cleansing  and  disinfecting  measures. 

1  Trans,  of  S.  Carolina  Med.  Association,  1872. 

2  This  was  illustrated  in  Philadelphia  in  1870,  when,  from  local  infection  from  a  foul 
vessel,  a  number  of  deaths  from  yellow  fever  occurred  at  the  Lazaretto;  but  none  in 
the  city,  although  several  of  the  patients  were  ill  there,  having  left  the  vessel  before 
being  taken  sick.  In  other  places  similar  instances,  disproving  the  personal  conta/- 
giousntiss  of  yellow  fever, .have  counted  by  hundreds,  if  not  thousands. 


R  E  L  A  r  S  r  N  G    FEVER.  455 

6.  A  ship  may  carry  yellow  fever  on  board  of  it  for  a  lenijth 
of  time  ((luriiiij;  warm  weather)',  and  to  a  great  distance  ;  hut  the 
disease  will  not  spread  far  from  the  ship;  at  least  unless  local 
conditions  add  their  propagating  inlluence. 

7.  Thorough  airing,  cleansing,  and  disinfection  of  ships  (espe- 
cially hy  dry  heat  or  superheated  steam)  vvill  always  deprive  them 
of  the  power  to  generate  or  transport  yellow  fever. 

H.  Against  yellow  fever,  the  true  prophylactic  method  must  he 
that  of  sanitary  police;  apart  of  which  should  be,  the  inspection, 
near  ports  liable  to  it, of  all  vessels  arriving  during  warm  weather.' 

9.  At  the  place  of  such  inspection  all  foul  vessels  should  be 
detained  until  cleansed,  being  first  emptied  of  their  passengers 
and  cargo.  The  cargo  also  should  be  inspected,  and,  if  unwhole- 
some, destroyed  or  disinfected. 

10.  'No  jjersonal  detention  whatever,  other  than  of  those  ill,  for 
necessary  hospital  treatment,  should  be  imposed  upon  the  pas- 
sengers or  crews  of  vessels  which  have  yellow  fever  on  board. 
There  are  no  facts  which  give  reason  for  any  such  detention. 

RELAPSING  FEVER. 

Prof.  Aitken-  thus  defines  this  disease:  "A  continued  fever, 
having  a  very  abrupt  invasion,  marked  by  rigors,  chilliness,  and 
severe  headache,  vomiting,  and  often  jaundice  ;  a  white,  moist 
tongue,  epigastric  tenderness,  confined  bowels,  enlarged  liver  and 
spleen,  high-colored  urine,  a  frequent,  full,  and  often  bounding, 
pulse;  pains  in  the  baek  and  limbs,  restlessness,  and,  occasionally, 
delirium.  These  symptoms  abruptly  terminate  by  an  exceed- 
ingly copious  perspiration  between  the  fifth  and  the  eighth  day ; 
and  after  a  complete  apyrectic  interval  (during  which  the  patient 
may  be  so  well  as  to  get  up  and  walk  about),  an  abrupt  relapse 
supervenes  on  the  fourteenth  day  from  the  first  commencement. 
The  relapse  runs  a  similar  course  to  that  of  the  primary  parox5'sm, 
and  terminates  between  the  third  and  the  eighth  day.  In  some 
cases  a  second,  third,  fourth,  and  even  fifth  relapse  may  occur. 
Death  is  apt  to  happen  from  sudden  syncope,  especially  after  the 
excessive  perspiration  ;  or  from  suppression  of  urine  and  coma. 
No  constant  eruption  and  no  specific  lesion  are  associated  with 
the  fever." 

The  temperature  generall}^  rises  to  104°  or  105°  F.  on  the  second 
day,  and  reaches  its  maximum  the  day  before  the  defervescence. 
Then,  as  the  other  symptoms  subside,  it  sinks  rapidly  to  about 
98°.  When  the  relapse  occurs  on  or  near  the  fourteenth  day,  the 
heat  again  rises  to  10'4°,  105°,  or  more ;  descending  afterwards 
with  convalescence. 

History. — Drs,  Christison  and  Welsh  first  described  relapsing 
fever  in  Scotland,  1817-18  ;  Barker  and  Cheyne  in  Ireland  about 
the  same  time.  Kutty  appears  to  have  given  an  account  of  it  in 
Dublin  as  early  as  1789.    In  1844,  Dr.  M.  Clymer  recognized  it  in 

1  The  substance  of  these  conclusions  was  clearly  advocated  by  Dr.  G.  Milroy,  1867, 
before  the  London  EpidemioloL'ical  Society. 

-  Science  and  Practice  of  Medicine,  Philadelphia  ed.,  vol.  i.,  p.  4.38.  See  on  Relapsing 
Fever  in  Philadelphia,  a  valuable  paper  by  Dr.  J.  S.  Parry,  in  Am.  Journal  of  Med. 
Sciences,  October,  1870. 


456  ZYMOTIC    DISEASES. 

some  Irish  emigrants  coming  to  the  Philadelphia  Hospital.^  Dr. 
Dubois  reported  the  occurrence  of  a  few  cases  in  ITew  York, 
mostly  among  emigrants,  in  1847-8.  In  the  same  years  it  was 
epidemic  in  Glasgow,  Edinburgh,  London,  and  some  parts  of  Ger- 
many, in  1855,  in  the  Crimea,  during  the  war;  and  since  that 
time  in  Russia,  and  elsewhere  on  the  European  continent.  Since 
1856  it  appears  to  have  almost  disappeared  from  Great  Britain. 
During  the  summer  of  1870,  in  New  York  and  Philadelphia,  hun- 
dreds of  cases  occurred  in  local  "nests  "  of  unsanitary  conditions. 
In  the  Philadelphia  Hospital,  from  April  to  November,  1870,  517 
cases  were  admitted,  with  80  deaths.  Of  this  mortality  (15.}  per 
cent.)  the  greater  part  was  amongst  negroes;  of  whom  26  per 
cent.,  affected  with  relapsing  fever,  died  ;  of  white  patients,  only  5 
per  cent.^  In  Great  Britain  the  deaths  have  been  reported  as 
about  1  in  40 ;  in  Russia,  10  or  11  per  cent,  of  the  cases. 

Diagnosis. — The  most  distinctive  features  of  this  fever  are,  the 
"crisis,"  from  the  fifth  to  the  seventh  or  eighth  day,  and  the 
relapse  on  the  fourteenth,  or,  at  all  events,  between  the  twelfth 
and  the  twentieth  day.  In  its  general  symptoms  it  resembles, 
otherwise,  remitting  fever;  but  with  less  decided  daily  abate- 
ment and  exacerbation  of  the  febrile  movement,  and  with  greater 
severity  of  "rheumatic"  pains  in  the  joints  and,  muscles.  The 
convalescence  is  slow,  and  is  not  unfrequently  attended  by  a 
severe  ophthalmia. 

Pathology  and  Causation. — It  would  seem  that  relapsing  fever 
must  be  a  specific  disease.  Associated  in  nearly  all  cases  with 
circumstances  of  destitution  in  large  cities,  it  has  been  called  in 
Europe,  "famine  fever."  Contagion  is  asserted  of  it  by  Prof. 
J.  Simon,  Dr.  E.  Harris,  and  others.  Carter,  Munch  and  Mots- 
chutkoffsky^  found  that  it  could  be  inoculated  by  means  of  the 
blood  taken  during  the  febrile  paroxysm.  In  the  Philadelphia 
Hospital,  in  1870,  it  did  not  spread  to  other  inmates. 

Anatomically,  it  has  been  observed,  in  fatal  cases,  that  the 
sjyleen  is  often  enlarged  to  a  greater  degree  than  in  any  other  fever. 
Dr.  Hand,  of  Philadelphia,  has  found  the  red  corpuscles  gran- 
ulated and  cranated ;  besides  (Cormack,  A.  Thompson)  increase 
of  white  corpuscles.  Dr.  Obermeier,  of  Berlin,  asserted  the  ob- 
servation of  minute  mobile  filiform  bodies  in  the  blood  in  this 
disease,  called  spirilla.  They  have  been  found  also  by  others,  but 
not  constantly.  Dr.  J.  R.  Lewis  believes  them  not  to  be  essential 
to  the  disease.* 

Treatment. — After  a  mild  cathartic  at  the  beginning,  and,  if 
headache  be  severe,  a  few  cups  or  leeches  to  the  back  of  the  neck, 
cooling  diaphoretics  may  be  given,  as  solution  of  citrate  of  potas- 
sium or  acetate  of  ammonium.  After  the  crisis,  quinine  and 
mineral  acids  may  be  used,  in  moderate  doses,  at  least  until  the 
relapse.  It  has  been  proved  that  this  (the  relapse)  will  not  be 
prevented  by  any  amount  of  quinine.     Many  patients  will  require 

1  Fevers,  etc.,  by  Meredith  Clvmer,  M.  D.,  Philadelphia,  3846,  p.  99. 

2  Philadelphia  Med.  Times.  March,  1871.  The  total  number  of  deaths  in  the  city, 
reported  to  the  Board  of  Health,  was  162,  of  which  107  were  of  colored  people. 

8  Centralblatt  fur  die  Med.  Wissenschaft,  1875,  xi.,  193. 
*  Lancet,  Feb.  28, 1880. 


CEREBROSPINAL     FEVER.  457 

support,  especially  in  the  third  week,  by  beef-tea,  etc. ;  some,  also, 
alcoholic  stimulation. 

CEREBRO-SPINAL  FEVER. 

Sjnionyms.— Oerebro-.s'pma^  Mcn'mgith ;  Spotted  Fever;  MaJig- 
nant  Purimrir.  Fever.  The  name  adopted  above  is  preferred  by 
me,  in  the  absence  of  sufficient  prepond(!rance  of  authority  or 
reason  in  favor  of  either  of  the;  other  names.  The  disease;  is  a 
fever,  or  systemic  disorder  ;  not  a  mere  local  phlegmasia.  It  has 
no  more  claim  to  be  called  cerebro-spinal  meningitis'  than  typhoid 
fever  has  to  be  called  enteritis,  or  scarlet  fever  faucio-jjhctri/nyitis. 
Yet  the  term  spotted  (or  petechial,  Wood)  fever  is  not  fully  justi- 
fied as  distinctive — because  only  in  a  minority  of  cases  it  exhibits 
any  eruption,  and  something  like  the  same  is  also  at  times  seen  iu 
typhus. 

History,— Often  obscurely  described,  this  disease  appears  to 
have  been  known  in  France  in  DUO  and  1482 ;  over  Europe,  or 
parts  of  it,  in  1503,  '10,  '16,  '17,  '28,  '45,  '59,  (Sicily)  '64,  '68, 
(Paris)  '69-'74.  Inl5S0,  it  was  at  Rome,  Venice,  andMadrid,  with 
great  mortality;  again  over  Europe  in  1582;  at  Trent,  1591, 
Florence,  1592  ;  at  various  places,  1616  and  1624.  Sydenham 
described  it  in  1661.  In  1661  and  '93  it  was  in  Italy  ;  and  in 
England,  1698,  1710, 1741 ;  in  Prussia,  1704.  Other  years  named 
for' it  are  1720,  '60,  '61  ;  1757  and  1788.  A  well-known  outbreak 
of  it  occurred  at  Geneva,  1805  ;  one  in  the  Prussian  army,  1806-7; 
in  Sicily,  1808;  at  Dantzic,  1811 ;  Brest  and  Mayence,  1813-14  ; 
Grenoble,  1814,  and  the  same  year  at  Paris ;  1815  at  Metz  ;  else- 
where in  1816  and  1823.  Afterwards  in  Europe  its  historians 
(under  the  names  mmingite  cerehro-spinale  fjjidemique^  cerebral 
tijphus,  and  tifo  upoplettico  tetanico)  speak  of  it  in  1832,  '37,  '39, 
'40,  and  almost  every  year  till  1850,  extending  over  many  places 
in  succession  as  far  as  Gibraltar  and  Algiers  at  the  south,  and  Scot- 
land and  Ireland  at  the  north.  From  1854  to  1861,  in  Sweden, 
jSTorvvay,  and  Holland.  In  North  Germany  and  Russia,  it 
is  said  to  have  prevailed  in  1863-4-5  ;  and  iu  Ireland,  1866  and 
1867. 

In  the  United  States,  its  first  recorded  visitation  was  in  1806,  in 
Massachusetts.  Then  it  gradually  spread  through  the  New  Eng- 
land States,  New  York  and  Canada,  from  1807  to  1812,  when  it 
had  reached  Philadelphia.  After  that  it  was  met  with  at  various 
places  until  1820  ;  but  not  with  great  frequency.^  BetAveen  1840 
and  1850  it  was  epidemic  in  several  of  the  Middle,  Western, 
and  Southern  States  (Kentucky,  Indiana,  Illinois,  Michigan, 
Missouri,  Tennessee) ;  also  in  1852  and  1858.  Next  we  hear  of  it 
in  1862-3;  most  clearly  in  the  descriptions  of  Dr.  Gerhard,* 
in  the  latter  3fear,  as  it  occurred  in  the  neighborhood  of  Phila- 
delphia.    Since  that  time   (at  which  cases  were  seen  especially 

II  regret  being  oblisted  to  differ  here  from  so  liiffh  an  authority  as  Professor  A.  Stille. 
See  his  "  Treatise  on  Cerebro-spinal  Menin<;itis,"  Philadelphia,  1867. 

2  Early  American  writers  upan  it  were,  North  and  Strong,  I8U ;  Gallop,  1815;  Miner, 
1825. 

STransaotions  of  the  College  of  Physicians  of  Philadelphia,  1863. 

39 


458 


ZYMOTIC    DISEASES. 


at  Frankford,  Falls  of  Schuylkill,  Manayunk,  and  l^orristown,  but 

only  a  few  in  the  city)  it  has 
been  observed  in  a  number 
of  places  in  Pennsylvania, 
New  York,  Ohio,  Indiana, 
Michigan,  Missouri,  Rhode 
Island,  Vermont,  Massachu- 
setts, Maryland,  and  the 
District  of  Columbia. 

Symptoms  and  Course. — 
The  attack  is  nearly  always 
sudden.  Chilliness,  terrible 
pain  in  the  head,  extending 
to  the  back  of  the  neck,  nau- 
sea and  vomiting,  are  the 
earliest  symptoms.  Delir- 
ium follows  ;  ending  not  un- 
frequently  in  coma.  Tetan- 
ic spasm  or  rigidity  of  the 
muscles  of  the  back  of  the 
neck  (and  sometimes  of  the 
back  and  limbs),  is  common. 
Convulsions  are  much  less 
so,  but  do  occur,  particularly 
in  the  young.  Painful  sensi- 
tiveness (hypersesthesia)  of 
the  whole  surface  of  the  body 
is  present  in  most  cases,  when 
there  is  no  coma.  Loss  of  sight 
and  hearing  may  take  place 
during  the  middle  period  of 
the  attack.  The  pulse  is  at 
first  slow,  then  accelerated, 
but  diminished  in  volume 
and  strength.  Respiration  is 
slower  than  natural  in  most, 
but  not  in  all  cases.  The 
tongue  is  usually  at  first  white 
and  moist ;  sometimes  natu- 
ral ;  in  prolonged  cases  it  may  become  yellow  or  brown.  The 
bowels  are  costive  or  natural. 

The  skin  has  almost  always  at  the  beginning  an  abnormally 
low  temperature.  When  reaction  occurs  it  does  not  become  very 
hot  as  a  rule.  Burdon  Sanderson  has  found  it  as  high  as  102°  to 
104°  in  children.  Near  the  time  of  death,  Wunderlich  has 
known  it  to  reach  107°,  108°,  110°.  Dr.  J.  Lewis  Smith  has 
found  the  temperature  morbidly  elevated  in  the  rectum,  when  it 
was  not  so  in  the  axilla.  Dryness  of  the  surface  is  most  com- 
mon, although  late  in  the  attack  profuse  perspiration  may  occur. 
Often  there  is  an  herpetic  eruption  about  the  lips. 

In  a  minority  of  the  cases,  though  varying  in  proportion  in 
different  epidemics,  S20ots  (petechise)  appear,  on  the  second  or 
third  day,  or  later  ;  on  the  neck,  breast,  or  limbs  ;  seldom  on  the 


Cerebro-Spinal  Fever.   (J.  Lewis  Smith. 


CEREBRO-SPINAL    FEVER.  459 

face.  They  are  of  difierent  dimensions,  from  tlie  size  of  a  pin's 
head  to  three-quarters  of  an' inch  in  diameter,  and  distinct ;  but 
not  elevated  nor  disappearin<j;  on  pressure.  Their  color  is  red, 
purple,  or  black.  Sometimes  they  remain  after  death.  They 
are  either  contijested  portions  of  the  skin,  or  subcutaneous  ex- 
travasations of  blood. 

The  duratina  of  fatal  cases  of  this  disease  is  generally  short. 
Some  die  in  three  or  four  hours;  many  within  twelve  or  twenty- 
four.  That  period  of  time  overpassed,  the  danger  becomes  less, 
but  a  fatal  result  may  still  occur,  even  after  a  number  of  days. 
The  first  four  days  are  the  most  perilous  to  life.  After  recovery, 
sometimes  blindness  or  deafness  may  remain;  sometimes,  with- 
out these,  a  staggering  gate  is  observed.^ 

Morbid  Anatomy. — The  blood,  during  life,  is  found  to  have  an 
excessive  proportionate  amount  of  fibrin  and  corpuscles.  After 
death,  when  this  has  taken  place  on  the  first  or  second  day,  no 
anatomical  changes,  even  in  the  brain,  have,  in  several  instances, 
been  found.  Most  generally,  however,  the  brain  and  spinal  cord 
show  some  alteration.  It  is  the  pia  mater  especially  in  which  con- 
gestion, at  least,  is  nearly  always  present.  At  the  base  of  the 
brain  most  of  all,  is  this,  often  with  serous  and  plastic  exudation, 
observed.  The  surface  of  the  hemispheres  also  may  be  diseased; 
and  next  in  frequency,  the  pia  mater  of  the  cervical  portion  of 
the  cord.  The  ventricles  of  the  brain  have  usually  an  excess  of 
fluid  in  them ;  serum,  either  clear  or  mingled  with  blood  or  pus. 
The  substance  of  the  brain  is  more  or  less  injected  or  congested  ; 
the  spinal  cord  occasionally  so.  Softening  of  the  brain  is  reported 
in  protracted  cases. 

No  other  lesion  or  appearance  is  shown  to  be  usual  in  this  dis- 
ease. A  few  observers  record  the  presence  of  rather  firm  fib- 
rinous clots  in  the  heart ;  a  larger  number,  enlargement  of  the 
spleen. 

Diagnosis. — From  typhus  fever,  this  is  known  by  the  sudden- 
ness of  its  onset,  the  early  period  of  danger,  and,  in  favorable 
cases,  the  rapid  recovery;  as  well  as  by  the  peculiarity  of  the 
eruption.  From  ordinary  inflammation  of  the  brain,  while  the 
diagnosis  may  be  very  difficult,  it  differs  in  the  unexplained 
abrupt  attack,  severe  from  the  start ;  in  the  lowness  of  temper- 
ature during  the  first  day  or  two ;  in  the  early  tetanic  tendency 
and  the  eruption  in  many  cases.  Malignant  scarlet  fever  resem- 
bles it  considerably  at  the  onset ;  and  so  does  the  chill  of  per- 
nicious intermittent.  Locality  and  season  will  designate  the 
latter;  age  and  exposure,  especially  the  former.  Fortunately, 
the  principle  of  treatment  is  not  essentially  diff'ei'ent  in  these 
affections,  at  the  stage  which  may  present  a  doubt. 

Prognosis. — More  than  half  the  cases  die.  Those  who  survive 
three  days  have  a  fair,  though  not  certain  prospect  of  recovery. 

Causation. — Of  either  sex  more  children,  and  of  adults  more 
males,  die  of  this  disease.  Coincident  with  the  circumstances  of 
war,  or  military  rrgime,  most  of  its  epidemics  have  been,  though 
not  all  of  them.     The  analogy  which  it  presents  to  typhus  sug- 

1  S.  W.  Mitchell,  Phlla.  Med.  Times,  Jan.  31, 1874. 


460  ZYMOTIC    DISEASES. 

gests  a  probable  relation  of  the  disease  in  causation  to  local  or 
atmospheric  contamination.  I  can  think  of  only  one  plausible 
hyi^othesis  ;  that  it  depends  upon  a  peculiar  zymotic  material,  or 
"  morbid  poison,"  generated  by  a  slow  change  in  human  or  ani- 
mal emanations,  such  as,  in  camp  or  garrison  life,  the  long 
unwashed  clothing  of  soldiers  may  particularly  engender.  Ex- 
posure to  cold  is  thought  to  predispose  to  it. 

According  to  Hirsch,  in  central  Europe,  very  much  the  largest 
number  of  epidemics  of  it  have  occurred  in  winter;  next,  in 
spring ;  and  the  same  has  been  found  true  in  the  United  States. 
In  1871-2,  a  number  of  cases  in  New  York  city  were  traced  by 
Dr.  Moreau  Morris  to  very  unsanitary  local  conditions.^ 

There  is  no  proof  whatever  of  personal  contagiousness  in  cere- 
bro-spinal  fever. 

Treatment. — We  must  lament  the  unsatisfactory  condition  of 
the  evidence  upon  this  subject.  Almost  all  agree  that  asthenia 
characterizes  the  disease,  most  of  all  at  the  beginnin£j.  The 
resemblance  to  pernicious  fever  has  suggested  the  use  of  quinine; 
and  several  very  positive  statements  are  made  of  success  with 
it  in  large  doses,  as  two  to  four  grains  every  hour  or  half  hour 
until  cinchonism  is  produced,  or  until  from  thirty  to  sixty  grains 
have  been  taken ;  afterwards  a  grain  or  two  every  two  or  three 
hours.  Some  practitioners,  upon  trial,  have  abjured  quinine 
altogether  in  this  disease.  Were  the  diagnosis  sure  in  any  case 
from  the  commencement,  I  should  feel  inclined  to  continue  the 
trial  of  it,  from  what  has  been  reported,  in  this  city  particularly, 
of  its  success. 

Opium  has  equally  enthusiastic  (Boudin)  advocates  and  oppos- 
ers.  Early ^  if  it  be  given,  must  be  the  time.  The  idea  of  those 
who  urge  it  is  to  give  of  it  a  grain  ever}'^  two  or  three  hours,  until 
an  opiate  sleep  is  produced ;  then  to  withdraw  it  and  give  it  in 
much  smaller  doses. 

Bromide  of  potassium  is  favored  by  Dr.  J.  Lewis  Smith^  and 
others  in  the  early  stage,  especially  in  children.  The  use  of  it  is 
justified  by  the  opinion  that  it  tends  to  produce  "contraction  of 
the  arterioles  of  the  encephalon,"  and  thus  to  relieve  cerebral 
congestion.  Dr.  J.  L.  Smith  has  been  disappointed  with  the 
effects  of  quinine  in  this  disease.  He  recommends  the  application 
to  the  head  in  the  early  stage,  of  bladders  or  bags  filled  with  bran 
mixed  with  pounded  ice.  Dr.  Borland,  of  Boston,  has  success- 
fully used  bromide  of  potassium,  with  ergot. 

Stimulation  with  brandy  or  whisky  is  generally  employed  in 
the  first  stage  with  freedom.  Dr.  Stille  considers,  however,  that 
general  experience  does  not  warrant  its  being  used  in  all  cases, 
but  only  when  the  signs  of  failure  in  nervous  power  occur.  Ex- 
ternal stimulation  is  of  course  indicated  ;  by  mustard,  direct  heat, 
friction  with  red  pepper  and  brandy,  or  hot  whisky  and  salt,  the 
hot  bath,  etc.  Dry  cupping,  or  in  some  cases  cut  cups  (when 
reaction  occurs),  to  the  back  of  the  neck,  will  be  proper ;  followed 
by  a  blister  at  the  same  place.  In  Germany,  leeching  behind  the 
ears  is  said  to  have  often  proved  useful. 

1  See  also  Clymer,  on  Cerebro-spinal  Meningitis,  1872. 

2  Amer,  Journal  of  Med.  Sciences,  October,  1873. 


TYPHUS     FEVER.  461 

Cantharides  (20  to  40  drops  of  the  tincture  every  hour  till 
rea(;tion),  camphor,  chloroform,  sulphite  of  sodium,  erij;ot,  and 
hydrate  of  chloral,'  have  each  had  laudation  from  some  who  have 
used  them.  Dr.  Joseph  Klapp,  of  Philadelphia,  informs  me  that 
a  number  of  cases,  some  very  severe,  have  recovered  under  his 
care,  to  whom  he  administered  tincture  of  chloride  of  iron,  in  lari^e 
doses :  25  drops  every  2  hours.  I  have  known  recovery  to  follow, 
in  one  case,  the  application  of  ice  to  the  Kpine.  But  more  posi- 
tively successful  experience  is  needed  to  give  the  profession  much 
confidence  in  the  treatment  of  this  affection.'' 

TYPHUS  FEVER. 

Synonyms.^ Ship  Fever;  Camp  Fever;  Jail  Fever. 

Symptoms  and  Course. — For  a  day  or  two  premonitory  weak- 
ness, headache,  and  loss  of  appetite  occur.  Then  a  cold  stage,  of 
variable  distinctness,  begins  the  attack.  In  rare  instances  it  is 
said  that  death  takes  place  in  this  stage  without  reaction.  Much 
more  commonly  fever  follows,  with  severe  headache,  great  heat  of 
skin,  pulse  120  (110  to  ISO),  but  compressible,  tongue  whitish  or 
yellowish,  bowels  costive.  Delirium  is  common,  especially  at 
night.  The  temperature  in  the  axilla  is  from  102°  to  108°;  gen- 
erally after  the  third  day,  105°-6°  in  the  morning,  106°-7°  in  the 
evening.     Muscular  debility  is  very  decided. 

For  a  number  of  days  this  condition  lasts  ;  the  patient  lying  in 
a  stupid  half-sleep  much  of  the  time,  muttering  to  himself,  easily 
roused,  but  soon  relapsing  again  ;  the  face  having  a  dusky  flush 
of  redness.  Hardness  of  hearing  is  present  in  most  cases.  Pos- 
itive coma  is  a  very  bad  prognostic,  but  is  not  infrequent.  Sup- 
pression of  urine  may  take  place  in  the  worst  cases ;  retention 
occurs  in  many  severe  ones.  The  tongue  grows  darker  as  the 
attack  progresses  ;  brown,  even  black ;  often  cracked  or  fissured ; 
and  it,  as  well  as  the  teeth,  may  be  covered  with  sordes. 

Toward  the  end  of  the  first  week,  in  most  cases,  a  rash  appears, 
of  little  and  numerous  red  papulae  (miliary  eruption),  all  over  the 
chest,  abdomen,  and  upper  parts  of  the  limbs.  They  are  accom- 
panied by  sudamina  (minute  vesicles)  in  many  instances  ;  by 
petechice  in  a  few.  Sometimes  a  strong  odor  comes  from  the 
body ;  but  I  have  never  noticed  this,  even  in  the  cases  of  ship- 
fever  from  Ireland  in  the  Pennsylvania  Hospital,  in  1847-8,  at 
which  time,  while  resident  in  the  Hospital,  I  took  the  disease 
myself  from  them. 

The  urine  is  scanty.  Generally  it  contains  an  excess  of  urea 
and  uric  acid,  with  a  deficiency  of  the  chlorides.  Sometimes 
there  is  actually  less  than  the  normal  amount  of  urea  eliminated  ; 
excreta  may  then  be  supposed  to  accumulate  in  the  blood, 
promoting  coma.     Costivene.'iS  is  the  general  rule  in  typhus. 

The  dicrotous  or  double  pulse,  and  subsultus  or  twitching  of  the 
tendons  at  the  wrist,  are  common.     Weakness  of  the  impulse  of 

1  Patton,  Indiana  Journal  of  Medicine,  July,  1870. 

*  See  J.  S.  JewuU,  M.  !>.,  Report  on  Cerebro-Spinal  Meningitis.  Chicago,  1866;  J.J. 
Levick,  M.  D.,  "Report  on  Spotted  Fever,  so  called,"  Trans.  Am.  Med.  Assoc,  1866;  A. 
Stillfi,  M.  D.,  Treatise  on  Cerebro-Spinal  Meningitis,  1867. 

39* 


462  ZYMOTIC    DISEASES. 

the  heart  is  often  noticeable  ;  sometimes  so  much  so  as  to  justify 
Dr.  Stokes's  diagnosis  of  "  typhous  softening."  Hypostatic  pneu- 
monia (i.  e.,  beginning  with  passive  congestion  of  the  lungs  pos- 
teriorly) is  the  most  frequent  complication  of  the  fever. 

The  duration  of  an  attack  of  typhus  is  generally  three  weeks. 
The  critical  period  is  usually  about  the  eleventh  day;  after  which 
defervescence  (the  decline  of  the  fever)  may  be  looked  for.  Occa- 
sionally death  may  take  place  within  five  days,  or  recovery  within 
fifteen  from  the  commencement. 

Morbid  Anatomy. — Absence  of  lesion  of  the  solids  has  been 
repeatedly  noticed.  The  blood  is  always  altered  during  life;  after 
the  early  stage  it  is  less  coagulable  and  darker  in  color  than  in 
health.  Passive  congestion  in  various  organs  is  observed,  as  in 
the  lungs,  brain,  liver,  etc.,  but  without  anything  characteristic. 

Patholog-y  and  Causation.— I^o  disease  affords  more  reason  for 
pronouncing  it  a  disease  of  the  blood  than  typhus.  Its  cause, 
demonstrably  in  many  cases,  is  ochlesis  or  crowd-poison;  the 
effluvia  from  human  bodies,  accumulated,  especially  in  cold 
weather,  in  small  and  ill-built  dwellings  of  the  poor,  and  most  of 
all  in  filthy  towns,  ships,  jails,  or  camps.  Having  been  thus  gen- 
erated, it  becomes  contagious ;  one  patient  having,  in  his  morbid 
emanations,  the  poisoning  power  of  a  whole  crowd.  Yet  the 
contagion  is  not  very  strong ;  many  who  are  exposed,  especially 
in  well-ventilated  places,  often  escaping  the  disease.  In  giving 
this  account  of  it,  candor  requires  me  to  add  that  the  spontane- 
ous origin  of  typhus  in  any  case,  apart  from  direct,  specific,  per- 
sonal contagion,  is  denied  by  such  eminent  British  authorities  as 
Drs.  W.  Budd,  Parkes,  and  others. 

Diag'nosis. — After  the  first  two  or  three  days  (during  which 
there  may  well  be  doubt  as  to  its  character)  the  only  probable 
question  will  be  between  typhus  and  typhoid  fever.  All  medical 
authorities  are  not  yet  agreed  as  to  the  non-identity  of  the  two 
forms  of  slow  continued  fever.'  A  large  majority,  however, 
regard  them  as  quite  distinguishable  during  life,  and  separated 
pathologically  by  the  absence  in  typhus  of  the  morbid  alterations 
of  Peyer's  glands,  and  those  of  the  mesentery,  characteristic  of 
typhoid  fever.  I  have  many  times  seen  typhus  and  typhoid  cases 
in  the  same  ward,  lying  side  by  side,  and  should  feel  confident  of 
being  generally  able  to  diagnosticate  them  by  the  countenance 
alone.  Under  the  head  of  Ti/phoid  Fever  the  clinical  differences 
will  be  enumerated. 

Prognosis. — Murchison  states  the  mortality  in  the  hospitals 
of  Great  Britain,  from  typhus^  to  be  one  death  in  five  cases, 

1  Dr.  J.  Hughes  Bennett,  for  example,  maintained  their  identity;  and  some  German 
writers  call  typhoid  "  abdominal  typhus."  The  definite  history  of  typhoid  or  "  enteric  " 
fever  began  witli  Prost,  of  Paris,  1804.  Louis,  1839,  studied  it  elaborately,  showing  the 
constancy  of  the  intestinal  lesions.  In  182.S,  Dr.  Enoch  Hale,  of  Massachusetts, 
described  two  forms  of  continued  fever.  Dr.  Gerhard,  upon  careful  autopsies  in  the 
Philadelphia  Hospital.announced  evidence  of  the  distinctness  of  typhus  from  the  typhoid 
or  "  dothinenterite  "  of  Louis  in  1835.  Dr.  A.  P.  Stewart,  of  Glasgow,  published  similar 
conclusions  in  the  same  year  ;  and  so  did  D.  R  Perry,  of  Glasgow,  and  Dr.  John  Reid, 
in  1836-7.  In  1846,  Dr.  W.  Jenner  commenced  an  investigation  into  the  subject,  whose 
results  most  physicians  have  accepted  as  decisive.  He  concluded  that  typhus  and 
typhoid  fevers  are  clinically  and  anatomically  distinct  as  well  as  dilTerent  in  causation. 
Dr.  (Tairdnerhas  recorded  cases  in  which  patients  convalescent  from  typhoid  fever  have 
taken  typhus  upon  exposure  to  its  contagion. 


TYPHUS     FEVER.  463 

Cheyne  and  others  in  private  practice  have  found  it  hut  one  in 
twenty  or  more.  I  have  not  seen  many  deatiis  from  it,  in  private 
or  hospital  pi'actice.  Prohahly  one  in  ten  or  fifteen  would  he  a 
fair  jreneral  estimate.  Bad  siiins  are,  great  feebleness  or  extreme 
rapidity  of  the  i)ulse,  ]n-ofound  coma,  hiccough,  suj)pression  of 
the  urine,  involuntary  defecation.  Pneumonia,  complicating  the 
attack,  increases  its  danger,  though  I  have  known  several  recov- 
eries notwithstanding  this. 

Treatment. — More  than  half  the  cases  of  typhus,  according  to 
my  observation,  require  alcoholic  stimulation,  as  well  as  concen- 
trated nourishment,  after  the  fourth  day.  But  not  all  the  cases, 
as  my  own,  among  others,  proved.  I  was  bled  on  the  second  day, 
the  diagnosis  not  beinii'  made  out;  and  leeched  on  the  third  day, 
freely,  on  the  back  of  the  neck;  yet  no  alcoholic  stimulus  was  i-e- 
quired,  after  the  typhous  nature  of  the  attack  was  clearly  shown; 
recovery  following  at  the  usual  time.  Drs.  Russell  and  Gairdner ' 
have  shown  (in  the  Glasgow  Fever  Hospital)  that  typhus  may 
be  treated,  in  many  cases,  without  alcohol.  In  nearly  a  thousand 
cases  their  mortality  was  about  nine  per  cent.  Dr.  A.  L. 
Loomis,-  of  New  York,  in  1S61-2,  treated  five  hundred  cases  of 
typhus,  in  tentfi,  without  any  alcohol.  His  mortality  was  one 
death  in  sixteen  cases.  At  the  same  time,  in  Bellevue  Hospital, 
under  the  large  use  of  alcohol  then  prevalent,  the  mortality  was 
one  death  in  every  six  cases.'' 

Dr.  Loomis  very  properly  urges  the  importance  of  having 
patients  with  typhus  placed  in  the  purest  and  freshest  atmo- 
sphere possible.  The  hospital  tent  will  always  be  better  for  them 
than  the  hospital  ward. 

We  may  begin  the  treatment  of  an  ordinary  case  of  typhus 
with  a  mild  laxative — e.  g. ,  a  moderate  dose  of  solution  of  citrate 
of  magnesium  on  the  second  day.  The  diet  at  first  may  be  of 
gruel,  etc.;  but  very  soon  must  milk  and  beef-tea  or  chicken  or 
mutton-broth  (or  an  alternation  of  these)  be  given  in  small 
quantities,  at  short  intervals,  to  support  the  strength.  Before 
the  first  week  is  out,  half  the  cases  will  need  wine  in  moderation; 
some,  brandy  or  whisky.  In  the  second  and  third  week,  more 
than  half  the  cases  will  require  steady  support  of  a  positive  kind. 
In  such  cases,  the  proper  routine  is  a  tablespoonful  of  brandy  or 
whisky  punch  (one  part  of  spirit  to  three,  two,  or  one  of  milk) 
every  two,  three,  or  four  hours,  and,  the  alternate  hours,  a  table- 
spoonful  or  two  of  lieef-essence  or  beef-tea. 

Of  medicines,  quinine  has  had  the  most  extended  trial  in 
typhus.  It  acts  well  as  a  tonic  in  1-  or  2-grain  doses,  four 
or  five  times  daily,  after  defervescence  has  begun;  i.  e.,  after 
the  tenth  or  twelfth  day,  usually.  Dr.  Dundas's  plan  of  treating 
typhus  early  with  large  doses  of  quinine  (renewed  of  later  years 
with  the  view  of  reducing  temperature)  is,  I  am  satisfied,  after 
seeing  some  trials  of  it,  futile  and  even  unsafe. 

Mineral  acids  have  acquired  much  reputation  in  typhus.     Dr. 


1  British  Meaical  Journal,  Aupr.  22,  ISGS. 

2  N.  Y.  :Mcd.  Record,  May  21,  1881,  p.  5G3. 

3  At  Bellevue  Hospital,  during  the  sprinc:  of  1881,  there  were  273  cases  of  typhua 
fever,  with  64  deaths.    K.  Y.  Med.  Record,  Aug.  13,  1881,  p.  190. 


464  ZYMOTIC    DISEASES. 

Flint  advises  dilute  sulphuric  acid;  Huss,  phosphoric  acid.  Mtro- 
muriatic  acid  I  have  known  to  produce  an  excellent  effect  in  the 
depression  of  the  middle  stage.  Large  doses  are  not  required; 
but  the  acid  should  be  given  several  times  in  the  day.  Some 
prefer  dilute  nitric  acid  [F,  165,  166].  Chlorine  ruaier  is  lauded 
highly  by  others.  Sulphite  of  sodium  and  carbolic  acid  may  be 
worthy  of  further  trial.  Co/fee,  given  by  Gaillasse  in  typhoid  fever, 
would  seem  a  reasonable  stimulant  in  a  low  stage  of  typhus  also. 

But  the  great  point  of  skill  will  be  to  determine  when  and  how 
far  to  stimulate.  Delirium  favors  the  probability  of  its  being 
needed  ;  especially  a  low,  muttering  delirium.  Of  course  a  very 
feeble  pulse  indicates  it.  On  trial,  when  the  pulse  grows  slower, 
the  skin  more  moist,  and  the  restlessness  or  delirium  is  quieted, 
the  stimulus  has  done  good,  and  should  be  continued.  If,  on  the 
contrary,  a  more  hurried  or  a  harder  pulse  follow,  with  heat  of 
head  and  dryness  of  skin,  and  wilder  delirium  or  deeper  stupor, 
it  should  be  stopped,  for  a  while  at  least,  or,  if  given,  be  dimin- 
ished in  amount, 

Catheterism  may  be  needed  for  retention  of  urine.  Inquiry  and 
inspection  should  determine  every  day  the  state  of  the  blaclder. 
Constipation,  through  the  attack,  may  be  overcome  by  enemata, 
or  by  small  doses  of  oil,  Eochelle  salt,  or  other  mild  laxative. 

When  the  coma  is  very  deep,  a  blister  to  the  back  of  the  neck 
may  do  good ;  and  so  may  sinapisms  to  the  extremities.  Great 
heat  of  the  head  may  possibly,  though  rarely,  render  proper, 
especially  in  the  first  week,  the  application  of  cold  water  to  the 
head.  Sponging  the  whole  body  daily  (best  at  night)  with  whisky 
and  water,  warmed,  is  extremely  comforting  and  beneficial. 

Hypostatic  pneumonia  in  typhus  cannot  be  treated  actively. 
Even  abstraction  of  blood  by  cups  is  hardly  ever  to  be  ventured 
upon.  Dry  cups,  between  the  shoulders,  and  a  blister  upon  the 
breast,  are  about  all  the  special  treatment  allowable.  It  is,  how- 
ever, possible  generally  to  prevent  hypostatic  pneumonia,  by  not 
allowing  the  patient  ever  to  lie  for  many  hours  together  upon  his 
back.  Let  him  be  turned,  once  in  a  while,  upon  one  or  the  other 
side. 

Prophylaxis. — Thorough  ventilation  is  the  only  (but  sufficient) 
security  against  the  generation  of  typhus  fever ;  and  this  is 
capable  also  of  almost  disarming  its  contagion. 

TYPHOID  FEVER. 

Synonyms. — Slow  Nervous  Fever;  Common  Continued  Fevers- 
Enteric  Fever;  Abdominal  Typhus  (Pythogenic  lever  of  Mur- 
chison). 

Symptoms  and  Course. — After  a  more  gradual  approach  than 
that  of  any  other  fever,  with  languor  and  debility,  anorexia  and 
headache  for  several  days,  bleeding  at  the  nose  and  a  bronchial 
cough  are  almost  pathognomonic  early  symptoms.  The  patient 
takes  to  bed,  with  fever  of  considerable  violence.  The  face 
acquires  a  dark  purple  flush.  He  lies  dozing,  perhaps  muttering, 
unless  disturbed,  all  day;  but  is  more  or  less  wakeful  and  delirious 
at  night.    Hardness  of  hearino^  is  common  from  the  middle  of  the 


TYPHOID    B'EVER.  465 

second  week.  Swelling  of  the  belly  ( tympanites)  comes  on  towards 
the  end  of  the  iirst  week ;  dtarrhoea  about  the  same  time.  Rose- 
colored  lenticular  spots  [laches  rowjes)^  disappearing  on  pressure, 
are  discovex'able,  few  in  number,  and  on  the  abdomen  only,  toward 
the  end  of  the  second  week  ;  they  continue  a  week  or  two.  Ten- 
derness on  pressure  in  the  right  iliac  region,  with  gurgling  under 
the  hand,  generally  exists.  Sudamina  over  the  chest  are  not 
unusual.  The  duration  of  the  typhoid  pyrexia  is  seldom,  from 
the  start,  nmch  less  than  two  weeks,  and  it  is  often  more ;  the 
whole  attack  of  typhoid  fever  may  be  protracted,  as  I  have  seen 
it,  to  two  or  three  months.  One  month  may  be  considered  the 
average  time,  from  taking  to  bed  to  leaving  it  convalescent. 

Late  symptoms  in  sevei'e  cases  are,  the  dicrotous  pulse,  sub- 
sultus  tendinum,  retention  (perhaps  suppression)  of  urine,  hemor- 
rhage from  the  bowels ;  and,  if  death  be  imminent,  hiccough, 
cold  sweats,  involuntary  discharges. 

In  protracted  cases,  great  emaciation  and  bed-sores  may  super- 
vene. Even  during  convalescence,  abscesses  in  various  parts  of 
the  body  may  give  trouble.  These  usually  affect  the  glands  or 
connective  tissue,  but  may  occasionally  involve  the  long  bones, 
lungs,  liver,  or  spleen. 

Danger  of  perforation  of  the  intestine,  from  deep  ulceration  of 
the  glands  of  Peyer,  exists  always  after  the  first  week,  until  late 
in  convalescence.  Patients  out  of  bed  for  a  week  or  two  have 
sometimes  died  from  this  cause.  Dr.  Harlan  reports^  a  case  in 
which  fatal  perforation  took  place  four  months  after  the  com- 
mencement of  an  attack  of  typhoid  fever.  Dr.  Da  Costa  men- 
tions it  as  happening  after  seven  months,  from  error  in  diet.  The 
occurrence  of  perforation  is  recognized  by  symptoms  of  severe 
peritonitis,  with  collapse.  The  result  of  this  is  almost  inevitably 
fatal ;  the  only  recorded  exception  being  reported  by  Prof.  6.  B. 
Wood.  I  saw  a  case  of  suppurative  peritonitis,  opening  exter- 
nally, which  recovered,  in  the  Philadelphia  Hospital,  several  years 
ago  ;  but  I  was  not  able  to  learn  the  antecedents  of  the  case. 

Temperature. — This  has  been  made  a  special  study  in  typhoid 
fever.  The  rise  from  98.5°  (the  normal  degree)  is  gradual,  during 
the  first  four  or  five  days  ;  reaching  104°  on  the  evening  of  the 
fifth  day  ;  sometimes  1U4:.5°.  An  attack  of  disease  in  which  on  the 
second  day  the  heat  in  the  axilla  is  as  high  as  104°,  is  not  typhoid 
fever  ;  and  the  same  exclusion  applies  if  from  the  fourth  to  the 
eleventh  day  the  temperature  falls  below  108°.  A  diflerence  of 
1°  or  1.5°  between  morning  and  evening  (greatest  heat,  the  latter) 
is  usual ;  the  reverse  is  not  a  good  sign.  The  marked  tendency 
to  a  morning  fall  and  evening  rise  of  temperature  is  almost  pathog- 
nomonic of  typhoid  fever.  Toward  the  end  of  the  second  week, 
lowering  of  the  heat  below  103°  is  always  favorable  ;  persistence 
at  a  104°,  105°,  or  106°,  shows  a  severe  case  ;  the  higher  the 
worse.  Sudden  increase  of  temperature  indicates  a  complicating 
inflammation  ;  as  pneumonia. 

Discharges. — Liquidity  of  the  stools  is  a  characteristic  of  this 
disease,  even  if  there  be  but  one  daily.     Generally,  after  the  mid- 

>  Trans.  Philada.  Pathol.  Soc,  1859. 

2E 


466  ZYMOTIC    DISEASES. 

die  of  the  first  week,  there  are  two  or  three  passages,  brownish 
with  a  slight  yellowish  tinge,  every  day.  From  the  very  begin- 
ning of  the  attack,  the  bowels  are  usually  susceptible  to  the 
action  of  purgatives  ;  a  teaspoonful  of  castor  oil  operating  readily. 
Excessive  diarrhoea,  at  a  middle  or  late  stage,  not  unfrequently 
adds  to  the  prostration  of  the  patient.  Hemoi'rhage  from  the 
bowels,  when  it  occurs,  is  most  apt  to  be  met  with  in  the  second 
or  third  week. 

The  urine^  through  the  attack,  is  commonly  scanty,  high-colored, 
excessive  in  the  amount  of  urea,  deficient  in  the  chlorides,  and 
sometimes  albuminous  in  severe  cases. 

Complications. — Pneumonia,  especially  the  hypostatic  form  (as 
in  typhus),  is  the  most  frequent.  It  has  been,  by  some  writers, 
denied  that  true  pneumonitis,  anything  more  than  passive  conges- 
tion, occurs  in  these  cases.  But,  in  the  analogous  instance  of 
typho-malarial  fever,  especially  when  the  scorbutic  diathesis  was 
also  present,  I  have  seen,  after  death,  more  than  once,  suppura- 
tion as  well  as  hepatization,  confined  altogether  to  the  posterior 
portions  of  both  lungs.  I  do  not  doubt  the  same  happening  in 
typhoid  as  well  as  in  typhus  fever. 

Inflammation  of  the  brain  may  complicate  typhoid,  more  often 
than  typhus  ;  but  it  is  not  common. 

Peritonitis  follows  when  perforation  of  the  ileum  takes  place. 
Examples  of  its  occurrence  without  that  accident  are  said  to 
have  been,  though  very  rarely,  observed. 

Relapses. — Even  after  seemingly  decided  convalescence  has 
taken  place,  a  relapse  may  occur,  with  return  of  all  the  symp- 
toms of  the  disorder,  including  (Da  Costa)  the  cutaneous  eruption. 
The  temperature  "bounds, "In  a  relapse,  almost  at  once  to  103° 
or  104° ;  returning,  as  in  ordinary  cases  of  the  fever,  in  a  zigzag  man- 
ner to  the  normal  degree,  with  convalescence.  This  second  attack 
seldom  lasts  so  long  as  the  original  one  ;  and  death  does  not  often 
result  from  it,  unless  perforation  of  the  bowel  takes  place. 

Sequelae.— Prolonged  debihty,  or  a  very  slow  convalescence,  is 
common.  The  mental  faculties  are  sometimes  enfeebled  for  weeks 
or  months.  Paralysis  is  an  occasional  sequela.  Abscesses  have 
been  mentioned  ;  they  may  occur  in  the  connective  tissue,  joints, 
lungs,  liver,  or  spleen.  Periostitis,  followed  by  necrosis,  of  the 
tibia,  femur,  or  humerus,  may  happen,  though  I  have  known  of 
but  two  such  cases.  Perforation  of  the  bowel  may,  as  already 
stated,  occur  after  convalescence  has  seemed  to  be  established. 

Morbid  Anatomy. — Omitting  variable  and  merely  occasional 
appearances,  the  parts  characteristically  affected  in  typhoid  fever 
are,  the  agminated  glands  or  patches  of  Peyer  in  the  small  in- 
testine, the  mesenteric  glands,  and  the  spleen.  Careful  study 
of  Peyer's  glands,  by  many  observers,  has  shown  that,  at  first, 
the  glands  thicken  and  become  elevated  from  one  to  three  lines 
above  the  membrane  around  them.  They  are  generally  at  this 
time,  reddened  ;  but  with  variable  depth  of  hue.  Sometimes,  after 
this,  a  sort  of  induration  occurs  ;  in  other  instances,  softening. 
Later,  ulceration  affects  many,  though  not  all,  of  the  altered 
glands  ;  and  this  process  may  go  on  until,  as  above  said,  it  may 
perforate  all  the  coats  of  the  intestine.     This,  however,  is  excep- 


TYPHOID    FEVER. 


467 


tional.  Tho  healiiiij;  of  the  ulcers  by  granulation  is  the  general 
rule.  Dr.  Murchison  has  reported  fatal  cases  of  sloughing  of  the 
intestine  without  perforation.'^ 

The  solitari/  dosed  glands  of  the  small  intestine  are  also  com- 
monly enlarged,  and  often  softened  or  ulcerated.  The  mesenteric 
glands  are  almost  uniformly  enlarged,  congested,  and  softened ; 
occasionally  they  suppurate. 

The  r)msdcsj  especially  the  recti  ahdnminis^  in  protracted  cases, 
have  been  shown  to  undergo  a  granular,  or  sometimes  a  waxy  or 
amyloid  degeneration ;  resulting,  in  the  rectus,  occasionally  in 
rupture  of  its  fibres. 

Pathology. — Typhoid  fever  is  believed  by  most  authorities  to 
be  a  general  or  systemic  disorder,  with  a  characteristic  second- 
ary local  lesion  in  the  intestines.  How  far  the  matter  deposited 
in  the  patches  of  Peyer  befoi'e  ulceration  is  specific,  is  a  question. 
Rokitansky  and  Carl  Wedl  have  believed  it  to  be  peculiar — the 
former  comparing  it  to  that  of  encephaloid  cancer,  the  latter  to 
tubercle.  I  do  not  believe  that  there  is  anything  propei'ly  to  be 
called  specific  in  its  nature. 

Latterly,  however  (1881),  under  the  prevailing  tendency  to  find 
a  "contagium"  for  almost  every  disease,  it  is  a  very  commonly 
taught  doctrine  that  typhoid  fever  is  eminently  a  specific  dis- 
order. Klebs'^  asserts  the  discovery  of  its  "microbes"  or  caus- 
ative micro-organisms.  Eberth,  Braulecht,  and  others  have 
made  similar  observations.^  Such  discoveries,  however,  require 
repeated  verification  by  several  observers  before  they  can  be 
accepted  in  science. 

Dr.  G.  B.  Wood  held  the  opinion  that  an  inherent  predisposi- 
tion to  the  disease  exists  in  many  persons,  analogous  to  the  tuber- 
culous, gouty,  and  rheuma- 
tic  diathesis.      This   seems  Fig.  122. 
very  probable.    Dr.  H.  Ken- 
nedy, of  Dublin,  has  (1873) 
advanced  a  similar  opinion. 

Another  view  is,  that  the 
affection  of  the  intestine  is 
primary  ;  and  that  the  "  ty- 
phoid "  symptoms  result 
from  the  absorption  into  the 
blood  of  morbid,  putrescent 
material  from  the  glands  of 
Pe3'^er,  producing  a  septcemid 
or  ichorcemia.  This  view  does 
not  appear  to  me  to  be  con- 
firmed by  the  usual  order  of 
events  in  the  disease. 

Causation.  —  More    room 
for  doubt  exists  as  to  this  in 
typhoid  fever  than  in  regard  to  any  other  common   disorder. 
Depressing  causes  of  all  kinds   seem  to  promote   it ;   foul  air, 


Ulceration  of  Glands  of  Peyer. 


1  Trans,  of  Pathol.  Soc.  of  London,  1866,  p.  130. 

2  Archiv  fur  Exper.  Pathologie,  t.  xii.,  p.  231,  1880. 
8  Lancet,  May  7, 1881. 


468  ZYMOTIC    DISEASES. 

removal  from  home,  fatigue,  anxiety,  etc.  Yet  it  will  occur  in 
the  entire  absence  of  all  such  causes.  No  locality  limits  it ;  ail 
climates  allow  it;  from  the  Arctic  regions  to  those  bordering 
upon  the  tropical ;  from  the  cities  of  the  East  to  the  Rock}"^  Moun- 
tains. The  "mountain  fever"  of  hunters  in  the  far  West  was 
found  in  the  autopsies  of  Dr.  Hammond  to  present  the  lesions  of 
Peyer's  and  the  mesenteric  glands. 

buch  universality  is  very  much  in  the  way  of  the  "pytho- 
genic  "  theory  of  Murchison  (i  e.,  its  reference  always  to  foul 
air,  as  that  of  sewers),  or  that  of  Budd,  that  its  only  cause  is  a 
specific  matter,  passed  from  the  bowels  of  those  having  it,  and 
by  water  or  air,  conveyed  into  the  systems  of  others. 

Contagion  of  this  kind  is,  nevertheless,  widely  believed  in  now, 
especially  in  England.  Some  facts  asserted  (Flint,  Canstatt, 
Budd,  Watson)  in  proof  of  it  are  hard  to  explain  without  admit- 
ting such  a  mode  of  propagation  (e.  g.^  by  the  discharges  of  a 
patient  getting  into  a  well,  etc.,  so  as  to  contaminate  drinking- 
water).  Dr.  Ballard  has  reported'  instances  in  which  it  appeared 
to  be  propagated  by  the  milk  served  by  dairymen.  The  pans  used 
for  the  milk  appear  to  have  been  washed  with  .water  exposed  to 
contamination.  A  more  extensive  series  of  cases  in  the  west  end 
of  London,  in  the  summer  of  1873,  was  traced  to  the  same  mode 
of  propagation.^  Prof.  I.  Buckman  asserts  the  observation  of  a 
peculiar  "fungoid  or  confervoid"  growth  in  water,  contaminated 
by  sewage  or  otherwise,  and  productive  of  typhoid  fever.  But 
the  large  majority  of  cases  allow  of  no  such  explanation ;  most 
of  all  those  occurring  in  the  open  country. 

There  is  no  doubt  that  typhoid  and  typhus  fevers  may  coexist 
as  epidemics  ;  sometimes  affecting  the  same  patient,  the  one  fever 
shortly  after  the  other  (Gairdner);  and  occasionally  together,  as  a 
hybrid  disease.  This  may  help  us  to  account  for  some  instances 
in  which  foul  air  has  appeared  to  generate  typhoid,  and  where 
the  latter  has  seemed  to  be  contagious.  My  own  experience 
leads  me  to  adopt  the  view  expressed  by  Niemeyer,  Anstie,  and 
others,  that  "typhoid  fever  is  certainly  not  contagious  in  tlie 
same  sense  as  typhus  is."  Dr.  Murchison-^  states  that,  in  the 
Eever  Hospital,  in  fourteen  and  a  half  years,  with  2506  cases  of 
typhoid  fever  admitted,  only  eight  new  cases  originated  in  the 
hospital. 

Liebermeister  has  stated  (1865)  that  he  has  never,  in  the  hos- 
pitals of  three  cities  visited  by  him  during  many  years,  seen  a 
single  patient,  physician,  or  nurse  attacked  with  typhoid  fever, 
although  cases  of  it  were  placed  in  the  general  wards.  Dr.  R. 
Bruce  Low,  of  Yorkshire,  England,  has  reported  some  striking 
facts  showing  the  great  probability,  if  not  certainty,  of  the  orig- 
ination of  typhoid  fever  de  novo  in  isolated  localities.* 

Dr.  S.  S.  Turner,  of  Dakota,^  writes  thus:  "The  prairies  of 
Dakota  are  very  healthy.  The  air  is  exceptionally  pure  and 
invigorating.     And  yet  typhoid  fever  is  not  unkfie^n  here,  ae 

1  British  Medical  Journal,  Nov.  26,  1870;  Lancet,  April  5, 1873. 

2  Lancet,  Aug.  16,  1873.  3  on  Fevers,  p.  428. 
4  Philadelphia  Med.  Times,  Dec.  18,  1880,  p.  178. 

6N.  Y.  Med.  Record,  April  30,  1881,  p.  502. 


TYPHOID     FEVER.  469 

something  entirely  distinct  from  the  indigenous  mountain  mala- 
rial remittent  so  called.  An  occasional  '  sporadic'  case  is  seen 
at  military  posts  where  the  sanitary  conditions  are  seemingly 
the  best,  and  the  general  health  entirely  satisfactory.  I  have 
seen  the  same  thing  in  commands  living  in  tents  upon  the  dry 
prairie,  where  the  natural  conditions  were  perfect,  and  the 
privy-sinks  remote  from  the  camp.  These  cases  have  furnished 
perfect  clinical  histories  of  typhoid,  and  where  they  have  termi- 
nated fatally  the  pathological  conditions  were  found  to  be  typical, 
as  specimens  now  in  the  Army  Medical  Museum  will  testify." 

Dr.  Thorne  Thome's  so-called  "crucial  instance"  of  the 
extension  of  typhoid  fever  by  drinking-water^  falls  decidedly 
short  of  that  character,  since  the  presumed  initial  case  was  by 
no  means  certainl}'  one  of  typhoid  fever :  all  that  is  made  clear 
in  Dr.  Thome's  report  is,  that  the  man  had  diarrhoea,  but  was 
able  to  walk  about  and  be  at  work. 

In  a  number  of  places  in  the  country,  suspicion  has  fallen,  with 
reason,  upon  the  too  close  proximity  of  pi-ivies,  or  foul  drains,  to 
drinking  -wells,  as  a  promotive  cause  of  typhoid  fever.  More  than 
twenty  cases  were  thus  directly  accounted  for  in  Germantown, 
Philadelphia,  in  188U.  At  Zurich,  Switzerland,  in  1839  and  1878, 
epidemics  of  typhoid  fever,  with  440  cases  in  one  instance,  and 
about  500  in  the  other,  followed  immediately  upon  a  musical 
festival.  Investigation  connected  the  disease  with  the  use  of 
bad  veal,  furnished  by  an  innkeeper  of  the  place. ^  All  kinds  of 
foulness  no  doubt  promote  typhoid  fever.  This  I  believe  to  be 
the  true  solution  of  the  question,  in  regard  to  the  influence  of 
contamination  of  water  by  privies,  sewers,  etc. ;  there  being  no 
sufficient  proof  of  the  now  current  opinion,  that  the  disease 
depends  upon  a  "specific  infection"  or  "  contagiura "  passed 
from  the  bowels  of  a  typhoid  fever  patient,  which  must  in  some 
manner  get  into  the  body  of  another  to  produce  the  disease. 
Dr.  Austin  Flint^  writes  thus  :  "  under  ordinary  circumstances  it 
is  not  diffused  by  contagion;"  "facts  appear  to  show  conclu- 
sively the  spontaneous  generation  of  the  causative  agent  in  the 
great  majority  of  cases." 

Typhoid  fever  is  rarest  in  old  age  ;  not  frequent  in  childhood  ; 
most  common  between  fifteen  and  thirty  years.  Few  have  it 
under  ten  or  over  forty;  almost  none  beyond  fifty.  It  scarcely 
ever  (relapses  apart)  occurs  a  second  time  in  the  same  person. 

Diagnosis. — From  remittent  fever,  typhoid  is  known  by  the 
usual  absence  of  vomiting  and  of  sallowness  of  the  skin,  the 
slower  onset,  more  protracted  course,  the  hebetude  or  mental  dul- 
ness  and  drowsiness,  and  the  abdominal  symptoms.  Vomiting 
may  occur  in  children. 

From  typhus  fever,  the  distinctive  points*  are  as  follows  : — 


1  Practitioner.  June,  1879. 

2  Journal  de  Medecine,  June,  1S79. 

3  Practice  of  Medicine,  4th  edition,  1873,  p.  883. 

*  The  credit  of  iiist  establishing  the  non-identity  of  tvphus  and  tvphoid  fever  belongs 
to  Dr.  W.  VV.  Gerhard,  of  Philadelphia ;  1837.    See  note  on  p.  462.  ' 

40 


470  ZYMOTIC    DISEASES. 

In  Tyiohus.  In  Typhoid. 

No  epistaxis  nor  bronchitis  ;  Epistaxis  and  bronchitis ; 

Bowels  constipated  ;  Diarrhoea ; 

Belly  seldom  tympanitic  ;  Tympanites,  gurgling,  etc, ; 

Miliary  eruption,  5th  to  7th  day  ;     Lenticular  rose  spots  ; 

Progress  moderately  slow  ;  Progress  very  slow ; 

Death  often  within  ten  days ;  Death  rarely  within  14  days: 

Countenance  dusky  red  ;  Countenance  purplish  red'; 

Causation  mostly  obvious ;  Origin  obscure  ; 

Anatomy  not  peculiar.  Lesions  characteristic. 

As  Dr.  J.  W.  Miller^  has  pointed  out,  the  duration  of  elevated 
temperature  is,  in  typhus,  rarely  longer  than  eighteen  days  ;  in 
typhoid,  seldom  less  than  twenty-one  days,  and  often  more  than 
thirty.  In  typhus,  also,  the  evening  temperature  is,  not  unfre- 
quently,  lower  than  that  of  the  morning  ;  in  typhoid,  the  even- 
ing temperature  is  almost  constantly  higher  than  that  of  the 
morning. 

Cases  called  "febricula,"  or  "irritative  fever"  (formerly  "  sy- 
nochus")  are  described  by  some  writers,  and  met  with  once  in  a 
while  in  practice,  which  give  a  good  deal  of  trouble  in  diagnosis. 
Some  of  these,  probably  most  of  them,  are  mild  examples  of 
typhoid  fever.  A  few  may  be  called  walking  cases  :  the  patient 
being  able  to  keep  out  of  bed. 

Prognosis. — The  mortality  from  this  disease  varies  greatly 
under  different  circumstances.  The  possibility  of  perforation  of 
the  ulcerated  bowel  gives  an  element  of  uncertainty  to  every  case. 
Probably  one  death  in  twenty  cases  will  represent  its  average 
mortality.  The  favorable  and  unfavorable  symptoms,  other  than 
those  common  to  typhus  or  other  febrile  affections,  have  been 
indicated  sufficiently  already  in  our  account  of  the  disease.  The 
state  of  the  tongue,  especially  at  the  period  of  defervescence  (end 
of  second  week,  about),  should  alwaj^s  be  noticed,  as  it  aids  our 
observation  of  the  abdominal  symptoms  in  concluding  upon  the 
progress  of  the  intestinal  lesion.  Hemorrhage  from  the  bowels 
is  so  far  at  least  an  unfavorable  sign,  that  it  shows  the  intestine 
to  be  so  deeply  involved  as  to  make  perforation  not  improbable. 
Patients  before  robust  may  survive  a  quite  large  hemorrhage 
during  typhoid  fever.  If,  however,  repeated,  or  occurring  in  a 
feeble  subject,  it  presages  danger  of  exhaustion. 

Treatment. — Self-limited  as  typhoid  fever  is,  no  cutting  short  of 
it  is  possible.  We  must  conduct  the  patient  through  it  as  safely 
as  we  can.  For  this,  very  little  medication,  perbaps  none,  will 
suffice,  with  good  nursing,  in  many  cases.  I  have  treated  the 
disease  with  so  little  medicine,  that  it  might  be  said  to  have  been 
left  to  nature,  supported  by  regulated  liquid  nourishment  alone. 
Yet  this  is  not  always  proper  or  safe. 

The  course  of  treatment  learned  in  the  Pennsylvania  Hospital 
many  years  ago,  has  been  followed  throughout  my  practice  with 
generally  successful  results.     My  only  deviations  from  it  have 

1  Brit,  and  Foreign  Medico-Chir.  Review,  Oct.  1868,  p.  464. 


TYPHOID    FEVKR.  471 

been  in  the  direction  of  diminishing  the  amount  of  medicine 
given.     It  was,  upon  tl\c  aveirage,  as  follows  : — 

In  the  course  of  the  lirst  few  days,  if  the  bowels  were  costive,  a 
teaspoonful  of  castor  oil  was  given  ;  after  that,  no  laxative. 
During  the  first  week,  while  the  fever  was  highest,  the  tongue 
furred  and  often  dry,  skin  hot  and  without  perspiration,  small 
doses  of  blue  mass  with  ipecacuanha  were  prescribed,  with  the 
view  of  favoring  freedom  of  the  secretions.  Afterwards,  or  at  the 
same  time,  sjiiritus  mindereri  (liquor  ammonii  acetatis)  was  given, 
a  tablespoonful  (diluted)  every  two  or  three  hours,  from  noon  till 
near  midnight,  as  a  diaphoretic. 

Liquid  food  is  necessary  from  the  first.  Oatmeal  gruel,  toast- 
water,  rice-water,  the  first  three  or  four  days  ;  then  milk  may  be 
added,  one  or  two  tablespoonfuls  every  two  or  three  hours.  Less 
than  half  the  cases  of  typhoid  fever  which  I  have  seen  have 
required'  alcoholic  stimulation  at  any  stage  ;  not  more  than  one- 
fourth  of  the  cases  need  it  before  the  middle  of  the  second  week, 
when  the  fever  begins  to  decline.  After  that  time,  many  require 
it,  first  in  wine  whey,  half  a  wineglassful  about  every  three  hours  ; 
later,  when  weaker,  brandy  or  whisky  punch  ; — a  tablespoonful  of 
whisky,  for  instance,  every  four,  three,  or  two  hours,  sometimes 
every  hour,  with  the  same  or  twice  as  much  of  milk.  Sir  W. 
Jenner's  rule  is  undoubtedly  a  good  one,  "in  typhoid  fever  to 
abstain  from  giving  alcohol  if,  in  the  case  before  me,  I  doiM  the 
wisdom  of  giving  it ;  and  when  there  is  a  question  of  a  larger  or 
a  smaller  dose,  I,  as  a  rule,  prescribe  the  smaller  :  the  reverse  of 
the  rule  in  tj'phus  fever.  "^  Beef-tea  is  indispensable  in  nearly 
all  cases,  from  the  second  week.  It  may  alternate  with  punch, 
hour  by  hour.  As  in  typhus,  a  patient  prostrated  with  severe 
typhoid  fever  should  be  waked  from  sleep  to  take  the  required 
nourishment,  night  and  day  ;  otherwise  he  may  sink  for  want  of 
it.  Co/fee  has  been  used  as  a  stimulant  by  Guillasse,  with  asserted 
advantage. 

Quinine,  I  am  satisfied,  has  no  place  as  a  curative  of  this  fever. 
It  is  useful  as  a  tonic  after  the  critical  period  of  the  passing  of 
the  height  of  the  fever  ;  not  more  than  eight  or  ten  grains  (in  one 
or  two-grain  doses)  in  twenty-four  hours  [F.  2].  1  am  not  a 
believer  in  the  validity  of  the  "antipyretic"  action  of  quinine, 
in  continued  fever,  in  twenty-grain  doses  ;  and  am  glad  to  be 
able  to  quote  the  authority  of  Sir  William  Jenner  to  sustain  my 
want  of  confidence  in  it. 

In  the  first  ten  days,  headache  and  heat  of  the  head  may  call 
for  the  application  of  cold  to  it ;  sometimes  for  leeches  to  the 
temples  or  back  of  the  neck.  Dryness  and  heat  of  the  surface  of 
the  body  may  be  best  allayed  by  sponging  all  over  (one  part  only 
uncovered  at  a  time)  with  tepid  whisky  and  water.  This  opera- 
tion, done  in  the  evening,  will  promote  sleep.  Dr.  Drasche,-  of 
Vienna,  introduced  the  systematic  use  of  cold  water  externally, 
to  lower  the  temperature,  which  is  morbidly  increased  in  fever. 
Brand,  Liebermeister,  Ziemssen,  Wilson  Fox,  and  others  have 
appUed   this  remedy   extensively,   and   with    reported   success. 

•  Lancet,  Nov.  15,  1879. 

«  British  Medical  Journal,  Feb.  19,  1870. 


472  ZYMOTIC    DISEASES. 

Ziemssen's  gradual  method  is  the  best :  immersing  the  patient, 
when  the  heat  is  excessive,  in  a  bath  at  95°  F.,  the  temperature 
of  which  is  gradually  lowered  ten  or  even  twenty  or  more  degrees, 
according  to  the  efiect  produced.  In  this  way,  morbid  heat  may 
he  lessened,  without  shock  or  undue  depression.  On  the  whole, 
the  mortality  of  typhoid  fever  does  not  seem  to  be  lessened  by  its 
treatment  with  cold  bathing.  Eiess  (1780)  uses,  instead,  pro- 
longed lukewarm  baths.  ]!ianassein,  of  St.  Petersburg,  prefers 
cold  enemata. 

Great  tenderness  of  the  abdomen  may  be  treated  by  application 
of  large  poultices  of  hot  mush,  with  which  one-fourth  or  one-fifth 
part  of  mustard  has  been  stirred.  Diarrhoea  being  a  symptom  of 
the  disease,  it  needs  not  to  be  checked  unless  the  passages  num- 
ber more  than  three  or  four  a  day,  or  are  uncommonly  copious. 
Then,  a  pill  of  tannic  acid  and  opium  (3  grs.  of  the  former  to 
gr.  -4-  of  the  latter),  2^to  re  nata — or  small  doses  of  paregoric  or 
laudanum,  will  generally  reduce  it.  Earely  is  it  necessary  to  use 
laudanum  and  starch  enemata,  or  to  add  acetate  of  lead  to  opium 
in  iDill.  Hemorrhage  from  the  bowels  is  not  apt  to  continue  long, 
or  to  be  often  dangerous.  If  it  should  be  so,  astringents,  as  lead 
and  opium,  by  enema  or  by  the  mouth,  must  be  used. 

Shall  we  attempt  to  medicate  the  affection  of  the  glands  of  Peyer? 
This  also  being  symptomatic,  its  palliation  only  appears  to  be 
indicated.  I  am  not  satisfied  that  any  special  treatment  for  it  is 
demanded  in  mild  ordinary  cases.  But  if,  after  the  tenth  or  twelfth 
day,  the  defervescence  does  not  take  place,  and  restlessness  is  great, 
with  abdominal  tenderness,  a  dry  tongue  and  considerable  diar- 
rhoea, oil  of  turpentine  is  recommended  by  authority  (Wood)  and 
experience.  The  dose  should  be  not  more  than  ten  drops  four 
times  daily  in  mucilage,  with  a  few  drops  of  laudanum.  jSTitrate 
of  silver  is  used  instead  by  some.  I  have  had  no  experience  with 
it ;  but  I  have  often  seen  the  good  effects  of  turpentine.  This  seems 
to  act  as  a  local  alterative  to  the  ulcerated  surface  of  the  bowel. 
Pecholier,  of  Montpellier,  gave  creasote,  3  drops  daily,  diluted 
with  lime-water  and  orange-flower  water,  to  sixty  hospital 
patients,  with  typhoid  fever,  as  an  "anti-zymotic"  remedy.  He 
asserts  that  it  lightened  and  shortened  the  attack.  Dr.  W.  Pep- 
per^ decidedly  prefers  nitrate  of  silver  ;  -}  of  a  grain  three  or  four 
times  daily  for  an  adult,  in  pill,  or  for  children,  in  a  mucilaginous 
mixture. 

When  hemorrhage  from  the  bowels  occurs,  it  is  very  important 
to  avoid  increasing  it  by  much  movement  or  change  of  position. 
Enemata  of  cold  water,  with,  in  serious  cases,  the  addition  of 
astringents  and  opiates,  will  be  likely  here  to  do  good  service. 
Of  course  it  is  necessary  that  such  enemata  should  not  be  of  too 
low  a  temperature,  or  be  repeated  so  frequently  as  to  cause 
depression. 

Attention  to  the  state  of  the  bladder,  day  by  day,  to  prevent  or 
relieve  retention  of  the  urine,  is  important.  Long-protracted 
cases  may  demand  a  great  deal  of  care  to  avoid  severe  bed-sores. 
In  anticipation  of  these,  when  threatened,  frequent  changes  of 

1  Plii]a.Med.  Times,  Feb.  12,  1881,  p.  299. 


PLAGUE.  473 

position  should  be  made,  and  the  parts  should  be  bathed  with 
whisky,  spirits  of  canii)hor  mixed  with  olive  or  lard  oil,  or  soap 
liniment.  The  bed-elothes  must  be  kept  smooth  under  the  person. 
Adjustment  of  pillows,  with  the  addition  of  small  ones  made  for 
the  purpose,  may  do  much.  When  a  part  is  unavoidably  pressed 
upon,  it  may  be  protected  by  a  piece  of  kid  spread  smoothly  with 
soap  plaster,  or  adhesive  plaster.  Actual  excoriations  must  be 
treated  like  ulcers — with  simple  cerate,  lime-water,  poultices, 
adhesive  plaster,  etc.,  according  to  their  condition. 

PLAGUE. 

Of  this  oriental  disease,  now  fast  being  extinguished,  little  need 
be  said  here.  It  was  probably  plague  of  which  Thucydides  gave 
account,  at  Athens  during  the  2d  Peloponnesian  war.  Livy 
describes  an  epidemic,  probably  of  plague,  at  Rome  ;  Procopius, 
in  Egypt  and  Palestine,  in  the  6th  century  ;  Boccaccio,  at  Flor- 
ence, in  the  14th  century  ;  and  Defoe,  in  London,  near  the  end 
of  the  17th.  Its  last  outbreak  at  Marseilles,  in  1720,  destroyed 
nearly  half  of  the  population.  Before  that  time,  it  had  occa- 
sionally reached  Paris  also,  and  some  of  the  German  cities.  In 
1828-29,  it  prevailedwith  severity  amongst  the  Russian  soldiers  in 
Bulgaria.  In  1 876,  it  occurred  at  Bagdad,  Hillah  and  other  towns 
in  Mesopotamia  ;  and  in  1877-78,  in  scattered  locahtiesin  Russia. 
Early  in  1879  it  proved  very  destructive  at  Yetlianka  and  a 
number  of  other  fishing  villages  extending  for  a  hundred  miles  on 
both  sides  of  the  river  Volga.  All  of  these  villages  are  described 
as  having  been  in  a  very  filthy  condition.  Early  in  1881,  a 
number  of  deaths  from  plague  were  reported  as  occurring  in  and 
near  Bagdad.  Plague  is  a  zymotic  aflection,  allied  to  the  fevers, 
of  rapid  course  and  great  mortality.  Its  symptoms  are  debility, 
restlessness,  fever,  delirum,  vomiting,  hemorrhages,  petechise,  and 
glandular  swellings,  especially  in  the  axilla,  or  carbuncles. 
Death  often  takes  place  in  two  or  three  days.  Sometimes,  how- 
ever, the  case  may  last  for  two  or  even  three  or  four  weeks.  The 
characteristic  buboes  occur  in  the  axilla,  neck  or  groin  ;  always 
originating  in  enlarged  lymphatic  glands.  They  vary  in  size 
from  that  of  a  chestnut  to  that  of  a  goose's  egg.  Maturing 
toward  the  middle  of  the  second  week,  when  the  fever  has  already 
begun  to  decline  in  favorable  cases,  many  of  them  undergo  resolu- 
tion ;  others  suppurate.  Carbuncles  are  met  with  in  not  more  than 
one-fifth  of  all  the  cases ;  their  appearance  is  usually  later  than  that 
of  the  buboes.  Appearing  upon  any  part  of  the  body,  they  are 
most  frequent  on  the  legs.  They  begin  as  red  pimples  ;  the  mildest 
form  vesicles  which  burst  and  dry  up  ;  the  worst  pass  to  a  gan- 
grenous condition  ;  involving  all  the  surrounding  tissues. 

While  plague  is  almost  entirely  a  disease  of  hot  or  warm 
climates,  its  epidemics  decline  or  cease  at  the  height  of  the 
tropical  summer. 

Plague  was  once  thought  to  be  the  most  contagious  of  diseases. 
Excellent  reasons  are  given,  however,  for  believing  it  not  person-: 
ally  contagious  at  all ;  but  locally  infectious.  Not  quarantine, 
but  sanitary  police  and  hygienic  improvements  in  the  great  cities 
(Cairo,  in  Egypt,  for  example)  have  almost  put  an  end  to  it. 
40* 


474  ZYMOTIC    DISEASES. 

In  treatment  of  plague,  diaphoretics,  opiates,  and  mineral  acids 
are  best  reported  of.  Polli's  treatment  with  the  sulphites  might 
be  tried  in  it  with  propriety ;  and  also  that  with  carbolic  acid, 
benzoate  of  sodium,  etc.,  in  small  doses. 

ERYSIPELAS. 

Synonyms.^ — St.  Anthony''s  Fire ;  Bose. 

Varieties. — Traumatic  and  idiopathic.'^ 

Symptoms. — These  are  both  local  and  general.  Sometimes  the 
former  and  sometimes  the  latter  appear  first.  Idiopathic  erysipe- 
las generally  begins  with  an  ill-defined  cold  stage,  followed  by 
fever.  The  eruption  most  often  commences  on  the  face,  with  sore- 
ness to  the  touch,  and  redness  ;  which  spread  like  a  slow  confla- 
gration, from  part  to  part.  This  character  of  continuous  diffusion 
or  spreading  is  pathognomonic.  Heat  and  moderate  swelling 
attend  the  eruption.  It  may  extend  almost  all  over  the  body. 
It  may  also  be  superficial  and  transient,  or  the  inflammation  may 
involve  the  subcutaneous  cellular  tissue  (especially  on  the  limbs), 
causing  suppuration  and  sloughing. 

The  fever  of  erysipelas  has  no  special  features,  nor  has  the 
disease  any  definite  period  of  duration.  When  the  scalp  is  the 
seat  of  the  eruption,  delirium  is  common,  and  inflammation  of 
the  brain,  or  fatal  coma,  may  follow.  Otherwise,  the  danger  of 
the  disease  seems  to  be  from  suppression  of  the  function  of  the 
skin,  and  exhaustion.  Traumatic  or  secondary  erysipelas  com- 
bines the  danger  of  the  disease  itself  with  that  of  the  injury, 
abscess,  or  other  local  affection  from  which  it  starts.  Sthenic  and 
asthenic  forms  or  types  of  the  disease  may  be  discerned,  according 
to  constitution  and  circumstances. 

Erysipelas  is  often  destructive  in  surgical  hospitals,  as  an 
endemic  or  infectious  malady.  Ventilation  and  cleanliness  will 
do  much  towards  its  prevention.  Absolute  contagion  is  not 
proved  of  it ;  but  the  theory  of  •'  continuous  molecular  change  " 
(Snowj  applies  very  well  to  it.  The  immediate  promotive  cause 
of  it  would  seem  usually  to  be  accumulation  of  effete  material 
thrown  off"  from  the  human  body  in  connection  with  inflammation. 
It  appears  most  probable  that  erysipelas  is,  pathologically,  a 
capillary  li/mjjhangitis,  i.  e.,  inflammation  of  the  minutely  distrib- 
uted lymphatic  vessels  of  the  skin. 

Treatment. — ^As  above  remarked,  erysipelas  may  be  more  or 
less  sthenic  or  asthenic.  Thus  we  may  account  for  the  diverse 
views  and  results  of  its  treatment.  It  is  very  common  now  to 
treat  erysipelas  with  free  stimulation.  Yet  I  do  not  remember 
ever  to  have  lost  a  case  of  erysipelas,  in  which  life  was  not 
already  in  serious  danger  from  a  previous  injury— either  in  private 
or  hospital  practice.  Nor  have  I,  in  more  than  a  very  few  out  of 
a  large  number  of  cases,  found  occasion  to  give  any  alcoholic  stimu- 
lant whatever. 

I  have  commonly  begun  the  treatment  of  an  attack  of  the 
disease  with  a  mild  saline  cathartic  — as  a  small  dose  of  Epsom 

1  Billroth  asserts  tliat  erysipelas  always  depends  on  morbid  lymphatic  absorption. 
This  is  doubtful ;  since  the  degree  in  which  the  lymphatic  vessels  are  involved  varies 
mucli  in  diflFerent  cases. 


FLOOD    FEVER    OF    JAPAN.  475 

salts,  or  one  of  Rocliellc  sjiltor  citrate  of  magnesium.  Then  blue 
pill  with  ipecac,  if  tlie  stomach  be  good  (gr.  ■}  of  the  former  with 
gr.  i  or  gr.  \o(  the  latter,  every  three  hours)  and  neutral  mixture 
or  Uquor  ammonii  acetatis.  Asthenic  cases  appear  to  gain  by  the 
free  use  of  iron — twenty  drops  of  the  tincture  of  the  chloride 
every  three  hours.  After  C.  Hamilton  Bell,  some  ])ractitioners 
use  tincture  of  chloride  of  iron  in  all  cases  of  erysipelas.  I  am 
not  convinced  of  the  propriety  of  this  practice.  Dr.  Da  Costa 
generally  gives  quinine  as  well  as  iron. 

Locally,  mild  emollient  applications  are  the  best,  unless  as 
cordons  sanitaires,  or  lines  of  demarcation.  At  the  very  start, 
lard,  tallow,  or  cold  cream  may  almost ''  put  out  the  fire"  at  once. 
Mucilage  of  slippery  elm  bark,  or  of  flaxseed  and  diluted  lead- 
water,  are  all  that  my  experience  justifies  for  application  to  the 
eruption  itself.  I  would  not  try  to  suppress  it.  I  think  I  have 
seen  one  death  result  in  the  practice  of  another  physician  from 
the  attempt  to  do  this  with  nitrate  of  silver  over  a  large  surface  ; 
cerebral  congestion  and  coma  taking  place. 

Solution  of  bisulphite  of  sodium  has  been  used,  internally 
and  externally,  with  great  asserted  advantage.  A  solution  of 
camphor  in  ether  is  said  to  have  proved  useful  in  some  cases. 
Cavazzani'  adds  to  this  combination  tannic  acid  (camphor  and 
tannin,  each  15  grains  ;  ether,  2  drachms). 

To  head  off  the  eruption  is  perhaps  only  worth  while  when, 
from  the  face,  it  is  spreading  to  the  head.  Tincture  of  iodine, 
or  strong  solution  of  nitrate  of  silver,  may,  for  this  purpose,  be 
painted  in  a  line  of  half  an  inch  in  width ;  or  a  narrow  strip  of 
fly  blister  may  be  put  on. 

A  seemingly  heroic  practice  (Hiiter,  1874)  is  said  to  have  been 
successful,  viz.,  the  hypodermic  injection  of  a  two-per-cent. 
solution  of  carbolic  acid  near  the  inflamed  parts ;  avoiding,  how- 
ever, the  most  vascular  tissues,  for  fear  of  carbolic  acid  poisoning. 
Rothe,.'^  of  Altenburg,  has  made  considerable  use  of  the  external 
application  of  carbolic  solutions  in  erysipelas.  Dr.  Radclitte,^ 
of  Washington,  D.  C,  reports  the  history  of  a  severe  case  in 
which  such  an  application  (carbolic  acid,  5ij,  with  olive  oil,  giv, 
put  on  freely  with  a  feather)  appeared  to  do  much  good. 

When,  in  traumatic  erysipelas,  a  limb  is  greatly  swollen  and 
inflamed,  threatening  destruction  of  the  subcutaneous  tissues, 
long  incisions  through  the  integument  to  relieve  pressure  and 
congestion  may  be  justifiable. 

A  milk  diet  is  usually  suitable  in  this  disorder. 

FLOOD  FEVEE  OF  JAPAN. 

This  disease  is  said  to  prevail  in  July  and  August  in  flooded 
districts,  aflecting  about  eight  per  cent,  of  those  residing  there. 
Beginning  with  rigor,  fever  follows,  nearly  continuous  for  about 
two  weeks,  with  constipation,  until  the  latter  part  of  the  attack, 
when  diarrhoea  may  occur ;  sometimes  deafness  and  delirium ; 


1  Lond.  Med.  Record,  Nov.  15,  1876. 

a  Deiitsch.  Med.  Wochenschr.,  .Tan.  22,  1881. 

3  Phila.  Med.  Times,  April  23,  1881. 


476  ZYMOTIC    DISEASES. 

temperature,  from  101°  to  104°.  Characteristic  of  the  disorder 
are  swelling  and  tenderness  of  the  lymphatic  glands  of  the 
neck,  axilla,  and  groin,  and  an  eruption  of  large,  flat,  dark-red 
papules,  with  smaller  lichenoid  spots  between  them.  The  glands 
become  tender  about  the  second  day,  and  the  eruption  appears 
on  the  sixth  or  seventh  day  of  the  attack.  Fatal  cases  have 
high  fever,  copious  bloody  stools,  maniacal  delirium,  and  coma. 
The  average  mortality  is  about  fifteen  per  cent,  of  those  affected.^ 
I  have,  so  far,  met  with  no  account  of  the  treatment  found  best 
for  this  disease. 

PUEEPERAL  FEVER. 

In  the  time  succeeding  confinement,  liability  always  exists 
(besides  the  transient  "milk  fever"  about  the  third  day)  to 
metritis^  and,  more  often,  peritonitis;  also,  but  with  much  less 
frequencj^,  to  that  asthenic  febrile  affection,  to  which  the  desig- 
nation pwerperaZ/euer  is  best  given. 

As  this  belongs  rather  to  obstetric  practice,  I  propose  only  a 
brief  allusion  to  it.  Beginning  with  a  chill,  its  symptoms  are 
fever,  with  an  extremely  rapid  pulse,  pain  in  the  abdomen,  and 
tenderness  on  pressure,  or  on  motion,  as  in  drawing  up  the  knees ; 
tympanites,  often ;  a  day  or  two  later,  vomiting,  delirium,  and 
tendency  to  collapse.  Death  may  occur  within  a  week ;  and 
more  than  half  the  cases  are  fatal.  Sometimes  the  pain  and 
tenderness  of  the  abdomen  are  slight  or  temporary  only ;  the 
general  debility  proceeding  still  to  the  fatal  end. 

Autopsy  shows,  in  much  the  larger  number  of  cases,  the  mani- 
fest lesions  of  peritonitis ;  serum,  lymph,  with  extensive  adhe- 
sions, or  pus.  In  a  few  cases,  however,  these  are  absent  entirely. 
Inflammation  of  the  uterine  veins  and  lymphatics  has  been  met 
with. 

In  causation,  it  is  observed  that  nearly  all  the  cases  of  this 
disorder  (distinct  from  simple  peritonitis  of  the  lying-in  room) 
take  place  in  towns,  or  in  hospitals,  especially  those  which  have 
surgical  as  well  as  obstetrical  wards.  Puerperal  fever  is  many 
times  endemic  in  such  localities.  Physicians  have  been  beset 
with  it,  in  some  instances,  in  practice,  as  a  "private  pestilence  ;" 
every  woman  attended  by  one  practitioner,  for  months  together, 
being  attacked  by  it,  when  others  have  none  of  it.  Hence  we 
infer  two  or  three  things. 

One,  that  this  fever  has  a  material  zymotic  cause,  which  may 
be  localized.  Another,  that  the  materies  morbi  seems  to  be  con- 
veyable  by  hand  from  person  to  person.  Although  disputed  by 
eminent  authorities,  the  evidence  preponderates  in  favor  of  this 
opinion.  Some  such  evidence  has  come  immediately  to  my  own 
knowledge.  Further,  several  morbid  poisons  appear,  in  the 
peculiarly  susceptible,  quasi-traumatic  state  of  the  womb  and 
abdomen  after  delivery,  to  promote  the  disease.  Erysipelas  does 
so,  or  at  least  the  conditions  productive  of  erysipelas ;  also,  the 
typhus  poison ;   perhaps  that  of  small-pox  and  scarlatina,  etc.^ 

1  Lancet,  Jan.  10,  1880. 

2  Dr.  O.  v.  Manson  described  malarial  puerperal  fever  in  the  Virginia  Medical  and 
Surgical  Journal,  1855. 


rUERPERAL    FEVER.  477 

As  to  erysipelas,  it  presents  a  close  and  striking  analogy  with 
puerperal  fever.     Thus : 

Erysipelas  is  an  acute  febrile  Puerperal  fever  is  an  acute  feb- 
ciisease,  occurring  most  often  rile  disease,  most  common  in 
in  surgical  hospitals,  in  whicli  lying-in  hos])itals,  in  which  a 
a  peculiar  diflusive  inllamma-  peculiar  diffusive  inflamma- 
tion is  a  prominent  character-  tion  is  a  prominent  character- 
istic ;  the  seat  of  this  inflam-  istic ;  the  seat  of  the  inflam- 
mation being  the  slm,  li/m-  mation  being  the  uterine 
phatics,  and  connective  tissue.  veins,    lymphatics,   and  2^^'^^''' 

toneum. 

Pathologically,  some  questions  are  not  yet  entirely  decided. 
Is  puerperal  fever  a  special  disease,  with  one  specific  morbid 
material  cause  or  virus  ?  or  is  it  a  cachcemia,  which  any  morbid 
poison  has  power  to  produce  during  the  lying-in  state  ?  or,  again, 
is  it  an  idiorhcemia,  from  absorption  of  foul  matter  from  the 
cavity  of  the  uterus  by  its  semi-patulous  sinuses  ?  or  a  pyaemia 
from  inflammation  and  suppuration  of  the  uterine  veins  V 

I  am  not  ready  to  answer  these  questions.  Perhaps  the  ichor- 
hcemic  theory  has  the  most  of  evidence  at  present  in  its  favor ; 
adding  to  that  the  hypothesis  of  "continuous  molecular  change," 
alluded  to  already  in  another  place.  Dr.  Ford3^ce  Barker  believes 
the  disease  to  be  a  specific  disease,  entirely  peculiar  to  the  puer- 
peral state. 

Practically,  sanitary  measures  of  precaution  are  clearly  indi- 
cated to  prevent  puerperal  fever.  One  of  these  is  personal.  It 
has  been  well  said  that  "an  offensive  post-partum  vaginal  dis- 
charge must  not  be  permitted.  It  must  be  prevented  by  skilful 
management  of  the  third  stage  of  labor,  by  insuring  efficient 
lochial  drainage,  and,  if  necessary,  by  washing  out  the  utero- 
vaginal canal  with  antiseptic  fluid."  For  this  latter  purpose, 
Dr.  J.  M.  Duncan'  prefers  a  solution  of  carbolic  acid,  1  part  in 
40  (occasionally  30)  of  tepid  or  warm  water.  Lying-in  hospitals, 
moreover,  must  be  great  evils,  rather  than  benefits,  unless  they 
have  the  best  possible  situation,  construction,  and  administra- 
tion. And  no  such  hospital,  or  ward,  should  ever  be  under  the 
same  roof  or  in  the  same  inclosure  with  a  surgical  ward  or  hos- 
pital. Moreover,  in  private  practice,  attendance  on  delivery  by 
a  physician  who  is  visiting  at  the  time  a  case  of  puerperal  fever 
or  of  erysipelas  is  at  the  risk  of  the  patient;  if  the  danger  of 
conveyance  of  the  disease  be  removable,  it  is  only  so  by  the  most 
careful  and  thorough  cleansing  and  disinfection.  The  clothes 
should  be  changed,  and  the  hands  washed  in  strong  solution  of 
chlorinated  soda  or  carbolic  acid,  before  making  such  a  transit 
from  the  one  patient  to  the  other.  Several  physicians  in  Phila- 
delphia always  decline  confinement  cases  under  the  circumstances 
named. 

Tlie  treatment  of  puerperal  fever  has  often  proved  unsatisfac- 
tory. I  had  intimate  knowledge  of  the  experimentation  to  which 
it  was  subjected  in  the  wards  of  the  Pennsylvania  Hospital  by 

1  Lancet,  Nov.  6,  1880. 


478  ZYMOTIC    DISEASES. 

the  late  eminent  Drs.  Meigs  and  Hodge,  between  1845  and  1849. 
Venesection,  purging,  and  mercurials,  etc.,  were  tried  amply,  and 
failed  most  signally. 

Quinine  in  tonic  doses,  with  beef-tea,  and,  if  collapse  be  threat- 
ened, alcoholic  stimulation,  has,  though  far  from  always  success- 
ful, had  at  least  better  results.  Leeching  the  abdomen  freely,  at 
the  beginning  of  the  attack,  in  the  least  asthenic  cases,  does 
in:iportant  good.  After  the  leeches,  for  a  day  warm  poultices 
may  be  applied,  then  a  large  blister.  Sulphites  and  carbolic 
acid  may  be  worth  trying  in  this  disease.  Behier,  "Winckel,  and 
Joulin'  speak  well  of  the  application  of  ice,  in  a  bladder,  to  the 
abdomen,  continued  until  a  reduction  of  the  temperature  has 
been  obtained. 

Por  the  personal  prophylaxis  of  puerperal  fever,  obstetricians 
of  authority  confirm  from  experience  the  reasonable  view,  that 
it  is  of  great  importance  to  empty  the  womb,  and  if  possible  the 
vagina,  thoroughly,  after  child-birth.  Good  uterine  contraction 
is  indispensable  as  a  safeguard.  Washing  out  the  vagina,  within 
a  few  hours  of  delivery,  with  lime-water  or  solution  of  glycerin, 
may  also  be  recommended  for  a  similar  end. 

CHOLERA.* 

Synonyms. — Epidemic,  Spasmodic.  Malignant^  Asiatic^  Indian 
Cholera;   Cholera  Algida ;    Cholera  Asphyxia ;  Mordshi. 

Symptoms  and  Course. — Premonitory  diarrhoea,  mostly  painless 
and  watery,  occurs  in  most,  but  not  in  all  cases.  Its  duration 
varies  from  an  hour  or  less  to  two  or  three  days.  The  worst 
epidemics  of  cholera  have  been  marked  by  some  cases  of  fearful 
rapidity.  In  India,  in  a  few  instances,  death  has  resulted,  by 
collapse,  in  ten  minutes. 

Commonly,  the  diarrhoea  increases  in  frequency  and  copious- 
ness, and  in  a  few  hours  vomiting  commences.  The  discharges 
are  colorless  or  "rice-water"  like,  and  are  spirted  out  with  spas- 
modic force.  The  skin  grows  cold  by  degrees,  and  great  debility 
comes  on,  with  cramps  in  all  the  limbs  usually.  "The  temper- 
ature in  the  rectum  and  vagina  has  been  several  times  found  to 
be  higher  than  natural.  Dr.  D.  AV.  Parsons^  asserts  a  constant 
difference  of  about  8°  between  the  axilla  and  the  tongue ;  the 
latter  being  the  colder. 

If  not  checked,  collapse  arrives  ;  with  intense  thirst,  oppression 
m  breathing,  loss  of  voice,  disappearance  of  the  pulse,  suppression 
of  urine,  cold,  hlue^  and  shrunken  skin,  sometimes  bathed  in  sweat, 
and,  at  last,  cold  breath ;  ending  in  death.  This  occurs,  on  the 
average,  in  about  eighteen  hours. 

When  reaction  takes  place,  recoveiy  may  immediately  become 
complete,  or  a  low  fever  may  supervene.  The  termination  of 
this  may  be  in  death  within  a  few  days,  or  recovery  in  a  week 
or  two. 

1  Am.  Journal  of  Med.  Sciences,  April,  1871,  p.  504. 

2  See,  for  the  fuller  statement  of  the  author's  views  upon  this  disease,  his  essay,  en- 
titled "Cholera:  Facts  and  Conclusions  as  to  its  Nature,  Prevention,  and  Treatnient." 
Philadelphia,  1866. 

8  Liverpool  Medical  and  Surgical  Reports,  October,  1871. 


CHOLERA.  479 

Appearances  after  Death.-:— /??Y/w^*<?/  occurs  soon;  sometimes  in 
less  tfian  an  hour;  generally  within  two  hours.  Startling  move- 
ments of  the  corpse  have  been  several  times  noticed  ;  as  of  a 
patient,  dead  with  cholera,  slowly  lifting  both  hands  over  the 
chest  and  joining  them ;  opening  the  eyes  and  rolling  them  down- 
wards, etc.  Increased  heat  of  the  body,  cold  during  the  attack, 
has  been  sometimes  observed  after  death.  Internally,  several 
of  the  great  organs,  the  brain,  spleen,  and  kidneys,  at  least,  are 
commonly  gorged  with  blood.  So  are  the  right  cavities  of  the 
heart ;  but  the  left  side  of  the  heart  is  empty  or  with  but  little 
blood,  and  firmly  contracted.  The  lungs  are  almost  bloodless. 
The  liver  varies  in  appearance ;  but  the  gall-bladder  is  almost 
always  full  of  bile.  The  urinary  bladder  is,  constantly,  greatly 
contracted.  The  stomach  and  intestinal  canal  are  congested  and 
swollen ;  the  late  Prof.  Horner  observed  the  frequent  throwing 
off  of  the  "epithelial"  lining  of  the  canal;  Buhm,  of  Germany, 
confirmed  this;  Drs.  Parkes,  Gull,  and  Lindsay  assert  it  to  be  a 
post-mortem  occurrence.^  The  intestinal  glands  are  found  con- 
siderably enlarged.  The  Hood  has  been  carefully  examined  by 
Drs.  Garrod,  Schmidt  of  Dorpat,  and  others.^  Its  water  and 
salts  transude  into  the  alimentary  canal,  with  some  of  the  albu- 
men and  fil:)rin ;  also  the  contents  of  the  blood-cells  transude  into 
the  serum.  The  blood  drawn  from  a  vein  during  life  is  (as  I  have 
seen  it)  dark,  thick,  and  tarry,  scarcely  capable  of  flowing. 
Schmidt  found  the  amount  of  oxygen  in  the  blood-corpuscles  less 
than  half  the  normal  proportion.  The  blood  is  acid  sometimes 
in  cholera ;  the  reverse  of  its  natural  reaction. 

The  gamjUa  of  the  "sympathetic"  system  have  been  often 
examined,  and  are  frequently  changed  in  appearance ;  congested, 
softened,  altered  in  color ;  but  no  special  change  has  been  shown 
to  belong  to  them  in  cholera. 

Diagnosis. — Common  cholera  morbus  alone,  when  severe,  re- 
sembles epidemic  cholera  so  much  as  to  be  easily  mistaken  for  it. 
The  collapsed  stage  of  the  one,  preceding  death,  is  almost  identical 
in  appearance  with  the  collapse  of  the  other.  But  cholera  morbus 
is  caused  by  some  irritant  of  the  stomach  and  bowels  and  is  clearly 
an  affection  of  those  organs^  not  a  toxcemia  or  systemic  disorder ; 
it  is  sporadic,  not  eindemic ;  in  it  the  discharges  are  always  bilious 
at  first,  and  mostly  so  to  the  last ;  collapse  in  any  degree  is  rare^ 
and  death,  under  judicious  treatment,  very  uncommon.  In  all 
these  things,  it  differs  greatly  from  Asiatic  cholera. 

History. — Putting  aside  some  possible  resemblance  to  this 
disease  in  descriptions  of  Aretaeus  and  one  or  two  other  ancient 
authors,  probably  the  epidemic  in  France,  of  1.545,  '■'■troussegalant^''^ 
came  more  near  to  it.  The  earliest  distinct  accounts  of  cholera 
were  given  by  D'Orta,  at  Goa,  15(33,  and  Bontius,  a  Dutch  phy- 
sician of  Batavia,  1629.  Willis  (1084),  Morton  (1692),  and  others, 
described  epidemic  fluxes  and  "dysenteries"  in  England  in  such 
terms  as  strongly  to  remind  us  of  cholera ;  and  so  did  Morgagni, 
in  Italy,  in  1733  ;  and  Degner,  of  Nymwegen,  in  the  Netherlands 

1  Edinburgh  Med.  and  Surg.  Journal,  January,  1855. 
-  Brit,  and  For.  Medico-Chirurgical  Review,  July,  1854. 


480  ZYMOTIC    DISEASES. 

(1736).  Some  British  physicians  (Greenhow,  Aitken)  now  believe 
that  cholera  may  have  repeatedly  visited  England.  It  appears  to 
me  more  probable,  however,  that  this  opinion  is  due  to  an  over- 
estimate of  the  resemblance  between  the  autumnal  cholera 
morbus  of  Great  Britain  (like  our  own)  and  the  pestilential 
disease. 

Certainly,  cholera  must  have  existed  in  India  for  an  indefinite 
time.^  Prom  1781-2  dates  its  extended  prevalence,  in  a  most 
destructive  form ;  at  Calcutta,  in  Madras,  on  the  Coromandel 
coast,  and  in  Ceylon. 

In  August,  1817,  Jessore  was  the  birthplace  of  the  first  great 
migratory  epidemic.  Shortly  after,  in  Calcutta,  36,000  were 
attacked  in  three  months.  At  many  militar}^  stations  it  was  very 
severe.  Roads  were  covered  with  dead  and  dying, unable  to  reach 
their  homes.  In  JSTovember,  the  grand  army  of  the  Marquis  of 
Hastings  was  devastated  by  it.  Of  90,000  men,  in  twelve  days 
9000  had  died.  On  marching  the  army  across  a  river  to  dry  and 
elevated  ground,  the  commander  was  relieved  of  this  otherwise 
invincible  enemy. 

In  1818,  the  Burman  empire  was  invaded  by  cholera;  and  there, 
and  elsewhere  in  Asia,  its  ravages  were  fearful.  In  1819,  160,000 
died  'of  it  in  the  Presidency  of  Bombay.  It  also  reached  Mau- 
ritius, 20°  S.  latitude,  three  thousand  miles  from  any  place  before 
visited  by  it.  The  Island  of  Bourbon  was  visited  in  1820;  as  well 
as  the  Philippine  Islands.  In  1821,  Borneo  and  Java  were 
afiected ;  and  a  large  Persian  army  was  repulsed  by  it  from 
before  Bagdad,  without  a  battle.  In  1822  its  limits  were  much 
narrowed,  and  its  destructiveness  abated. 

India  almost  escaped  in  1823,  but  China  was  ravaged  by  it;  and 
it  extended  northwestwax'd,  in  that  year,  to  Orenbourg,  on  the 
Ural,  near  the  borders  of  Europe  and  Asia.  In  1826,  it  passed 
the  great  wall  of  China  in  its  northwest  progress ;  but  almost 
left  Western  Asia.     It  reappeared  in  Persia  in  1829. 

Orenbourg  was  revisited  in  that  year,  and  the  epidemic  there 
lasted  from  August  till  near  the  end  of  February.  This  city  had 
a  population  at  that  time  of  11,000,  of  whom  6000  were  soldiers. 
Those  first  affected  had  no  communication  whatever  with  any 
infected  place. 

1831  saw  the  cholera  in  the  north  of  Europe,  as  far  as  Arch- 
angel, near  the  Arctic  Ocean,  more  than  64°  N.  latitude.  It 
reached  Warsaw  in  April,  during  an  insurrection,  and  was  very 
fatal.  Hungary  suffered  from  May  to  September,  losing  100,000 
of  its  population.  In  June,  St.  Petersburg,  and  in  Septemlaer, 
Moscow,  were  reached  by  the  pestilence.  Berlin  had  it  also  for 
three  months  and  a  half,  beginning  in  August.  Mecca  was 
attacked  during  the  visitation  of  throngs  of  pilgrims,  in  May ; 
of  50,000,  as  many  as  20,000  are  said  to  have  perished.  In  this 
year,  while  Hungary  was  infected,  the  Austrians  surrounded 
Vienna  by  a  double  cordon  militaire ;  but  in  vain.  The  disease 
began  there  in  August,  and  continued  for  three  months.     The 

1  Professor  Martin  Hang  has  found  some  distinct  references  to  it  in  ancient  Sanscrit 
writings.  Paisly  (1774),  Girdlestone  (1782),  Causis  (1794),  and  Jameson  (1820)  were  early 
English  authors  upon  it. 


ciioi.p]UA.  481 

southern  provinces  of  Austria  and  the  Rhincland  were  exempt. 
Constantinople  wasallected  \Ty  it,  but  not  with  very  great  severity. 
The  Turkish  government,  that  year,  maintained  no  quarantine. 
Cairo  sullered  dreadfully  in  1830-31 ;  and  so  did  Smyrna. 

Attacking  Hamburg  on  the  11th  of  October,  1H31,  it  was  offi- 
cially announced  at  Sunderland,  England,  October  2(jth,  It  had 
occurred  in  several  cases  in  England  months  before.  Three  or 
four  weeks  later  it  appeared  at  New  Castle ;  and,  in  December, 
at  Haddington,  a  Scottish  town  on  the  Tyne.  v 

Edinburgh  and  Glasgow  first  had  cholera  in  January,  1832 ; 
London  in  February ;  i)ubliu  and  Paris  in  March.  London  then 
suflered  moderately;  Paris  terribly — especially  in  April  and  May; 
20,000  deaths. 

On  the  8th  of  June,  it  first  invaded  our  continent,  at  Quebec ; 
and,  within  a  week,  at  Monti-eal.  In  the  same  month  it  was  in 
New  York  and  Albany.  Philadelphia  had  its  first  cases  in  July. 
Between  the  1st  of  July  and  the  18th  of  August,  New  York  had 
reported  5337  cases,  with  20G8  deaths.  That  city  lost  3518  in  all.^ 
From  the  27th  of  July  to  August  18th,  Philadelphia  had  1610 
cases,  with  015  deaths.  Boston  and  Baltimore  were  moderately 
alfected  in  August. 

Detroit,  Bulialo,  Elizabeth  City  in  North  Carolina,Wilmington 
and  Newcastle.  Delaware,  Norfolk  and"  Portsmouth,  Virginia, 
and  New  Orleans,  were  the  principal  of  more  than  fifty  towns  in 
the  United  States  reached  by  cholera  in  1832.  It  had  entered 
twelve  difterent  States  before  September. 

Havana  and  Mexico  were  attacked  in  the  spring  and  summer 
of  1833.  The  Citi/  of  Mexico,  notwithstanding  its  great  elevation 
above  the  sea,  did  not  escape. 

Portugal  was  also  first  visited  in  that  year ;  Spain  but  slightly 
until  1834.  Northern  Italy  was  affected  in  the  autumn  of  the 
same  year.  In  1835,  Alexandria  and  Malta ;  in  1836,  Rome, 
Naples,  Egypt,  and  Central  America,  especially  suffered.  North 
Germany,"South  France,  Rome,  Naples,  Sicily,  Malta,  Egypt,  and 
Syria,  in  1837.  After  that,  cholera  disappeared  from  Europe  and 
America  for  nearly  ten  years.  It  still  existed,  with  variable  vio- 
lence and  extciit,  in  India. 

In  1847,  it  ravaged  a  Russian  army  west  of  the  Caucasus ;  and 
in  September  it  returned  to  Moscow.  In  1841,  Turkey,  Russia, 
Austria,  Prussia,  Belgium,  Holland,  Great  Britain,  and  France 
(though  not  Paris)  were  successively  attacked.  Then  the  cholera 
showed  its  power  to  traverse  the  sea,  without  human  aid  or 
agency,  by  attacking  two  emigrant  ships,  a  thousand  miles 
apart,  one  sixteen  and  the  other  twenty-seven  days  out  from 
Havre,  when  710  cholera  was  prevailing  at  that  port ^  The  cholera- 
cloud  itself  also  reached  New  Orleans  about  the  same  time,  and 
progressed  up  the  valley  of  the  Mississippi.  New  York  was  not 
affected  by  the  visit  of  the  infected  ship;  the  disease  not  occur- 
ring again  there  until  May,  1849. 

'  In  1834,  New  York  lost  971 ;  in  1849,  5071 ;  in  1854,  2509.  Dr.  A.  Clark,  Lecture  on 
Cholera. 

-  Report  on  Cholera  in  the  United  States,  by  Dr.  James  Wynne ;  also,  Dr.  Gavin  Milroy, 
Brit,  and  For.  Medico-Chirurg.  Review,  October,  1865,  p.  444. 

41  2F 


482  ZYMOTIC    DISEASES. 

Paris  was  reached  by  it  in  February  of  that  year,  but  suflFered 
the  worst  in  June.  Lyons  now  had  it  for  tlie  tirst  time.  Tunis 
and  Algiers  were  visited  toward  tlie  end  of  the  year. 

In  January,  1849,  after  Memphis,  St.  Louis,  Missouri,  was 
attacked.  Chicago,  Buffalo,  and  other  towns  on  the  lakes  in 
May,  New  York  and  Philadelphia  in  the  same  month.  Baltimore 
had  this  year  only  a  local  epidemic,  in  July,  in  the  almshouse ; 
the  restriction  of  which  to  one  side  of  the  building  was  very 
remarkable.  As  in  1832,  the  mortality  in  Philadelphia  was  much 
less  for  the  population  than  in  Hew  York:  1022  deaths  occurred 
in  the  former  city ;  Kew  York  had  a  mortality  450  per  cent, 
greater.^     Canada  was  reached  this  time  from  the  westward. 

In  1848-49  the  number  of  deaths  from  cholera  in  England  and 
Wales  was  over  fifty-four  thousand  (54,398);  in  1832-33,  nearly 
thirty-one  thousand  (30,924).  In  London,^  probably  owing  to 
greater  attention  to  sanitary  measures,  the  mortality  was  two 
fifths  less  the  second  time  than  the  first.  Some  parts  of  Southern 
Ehineland  were  visited  in  1849 ;  especially  the  filthy  city  of 
Cologne. 

Cholera  lingered  in  various  places,  almost  sporadically,  in 
Europe  and  America,  from  1850  to  1854.  Canada  and  the  far 
West  (Indiana  also  had  cases  every  year)  suffered  the  most  in 
this  way,  on  our  continent.  In  the  West,  emigrants'  camps  and 
military  stations  seemed  especially  to  furnish  the  required  local 
conditions. 

In  1853,  Persia  had  it  severely;  also  some  parts  of  Northern, 
Central,  and  Southern  Europe  (Copenhagen,  Hamburg,  Berlin, 
Piedmont,  Lyons,  Paris,  and  Southern  Portugal).  Before  the  end 
of  the  year  it  was  again  in  New  York,  New  Orleans,  and  the 
West  Indies.  Mexico  had  been  visited  in  the  spring  and  through 
the  summer. 

1854  was  still  more  a  cholera  year  in  Europe  and  in  this  coun- 
try. Scarcely  any  European  state  or  kingdom  was  exempt.  The 
French,  English,  and  Russian  troops  sulTered  from  it  much  in  the 
Crimea.  Greece,  Italy,  Germany,  France,  Spain,  Portugal,  in 
short,  all  Europe  was  traversed  by  it ;  150,000  died  of  it  in  France 
alone  ;  in  England  and  Wales  about  20,000.  Newfoundland,  on 
our  side  of  the  ocean,  was  reached  for  the  first  time  in  1854. 
This  was  the  year  of  the  epidemic  at  Columbia,  Lancaster  county, 
Pennsylvania  ;  so  remarkable  for  the  absence  of  some  of  the  usual 
promotive  conditions  of  cholera.  Our  great  cities,  however,  did 
not  suffer  nearly  so  much  as  in  1849. 

In  1855  the  disease  was  widely  spread  in  Europe,  though  not 
very  malignant,  except  near  the  seat  of  war,  before  Sebastopol. 
Egypt  and  Palestine  had  it  also.  In  Switzerland,  which  had  been 
slightly  touched  before,  Basle,  Geneva,  Zurich,  and  other  places 
now  suflTered  by  it.  The  next  year,  1856,  still  did  not  witness  its 
withdrawal  from  Europe. 

Since  that  period  until  1865  I  have  no  means  at  hand  for  tracing 
the   movements  of  epidemic  cholera.     Dr.  Galvin  Milroy   says 

1  Dr.  J.  H.  Griscoin,  Medical  Becord,  March  15, 1866,  p.  35. 

2  London  had  13,098  deaths  from  cholera  in  1849 ;  in  1854,  about  10,000. 


CHOLERA.  483 

that  the  countries  hitherto  exempted  have  l)een  as  follows:  Aus- 
traHa,  New  Zealand,  and  other  islands  in  the  Paeific  ;  the  Cape 
of  Good  Hope  and  adjoining  settlements  ;  the  coast  of  Africa 
from  the  Cape  as  far  northward  as  the  Gamhia,  and  including 
the  islands  of  St.  Helena  and  Ascension  ;  the  Azores,  Bermuda, 
Iceland,  Faroe  Islands,  and  also  the  Orkney  and  Shetland  ;  the 
southern  half  of  the  eastern  coast  of  South  America,  from  the 
Rio  Plata  inclusive.  Cape  Horn,  and  the  whole  of  the  western 
coast  of  that  continent,  from  the  Cape  and  along  the  shores  of 
Chili  and  Peru  to  Panama. 

In  18G5  every  one  was  familiar  with  the  accounts  of  cholera  in 
Arahia  and  Egypt  in  the  spring,  at  Constantinople  in  July,'  and 
afterwards  in  several  parts  of  Europe,  extending,  though  with 
but  moderate  violence,  as  far  as  England.  While  its  vast  migra- 
tions seem  to  be  as  capricious  or  incalculable  as  the  flight  of  birds 
or  insects,  two  local  causes  contributed  at  least  to  its  severity  in 
Mecca  and  on  the  Nile.  These  were  the  crowds  of  religious  pil- 
grims at  the  former  place  in  the  spring,  and,  in  Egypt,  the  insa- 
lubrious circumstances  attending  the  operations  at  the  new  Suez 
Canal.  In  both,  "crowd-poison"  was  intensified  to  the  greatest 
degree ;  so  that  the  pest-cause  might  well  find  strength  for  the 
renewal  of  its  flight  onward  to  the  north-west.  In  Paris,  in 
1865,  6383  deaths  occurred. 

In  1866,  Europe  was  invaded  by  cholera  from  the  south.  In 
June  it  was  in  Egypt ;  then  in  Constantinople,  Malta,  Yalentia, 
Ancona,  Gibraltar,  Barcelona,  Madrid,  Toulon,  Paris,  Southamp- 
ton, Liverpool,  and  London ;  as  well  as,  on  this  side  of  the 
Atlantic,  in  New  York,  Philadelphia,  and  other  places.  In  1867 
also  it  existed,  though  less  destructively,  in  Europe  as  well  as  in 
the  West  Indies,  Central  America,  and  South  America.  In  1868, 
in  the  early  part  of  the  year,  it  continued  in  South  America, 
especially  in  Paraguay  and  the  Argentine  Confederation  ;  in 
which  it  destroyed  more  than  40,000  people.  It  was  in  part  of 
Russia  and  also  in  Cuba  in  the  summer  of  1870.  In  the  summer 
of  1871,  it  is  said  to  have  been  very  destructive  in  Persia ;  and 
considerably  so  in  some  parts  of  the  Russian  territoi-y  in  Europe. 
By  August,  it  had  reached  Konigsberg,  in  Germany,  threatening 
a  renewal  of  its  westward  course  ;  by  the  beginning  of  Septem- 
ber, being  reported  as  present  in  Dantzig,  Leipsic,  and  Vienna.^ 

In  1872,  also,  central  Europe  suUered  by  it ;  most  of  all  in  Hun- 
gary, Poland,  and  Prussia.  In  that  year  more  than  80,000  deaths 
from  cholera  occurred  in  Prussia  alone.  A  remarkably  localized 
visitation  of  cholera  occurred  in  the  latter  part  of  the  summer  of 
1873,  in  a  number  of  towns  in  several  of  the  United  States  ; 
especially  in  Kentucky,  Tennessee,  Illinois,  Indiana,  and  Ohio.* 

During  the  winter  of  1873-4,  cholera  was  present  in  some  por- 


1  The  first  case  occurred  in  that  city  on  the  28th  of  June. 

2  Au},'ust  15,  1871,  Dr.  lulmunds,  in  a  note  to  the  "  Times,"  reported  a  "tj-pical  case 
of  Asiatic  cholera"  in  London  ;  and  6  cases  are  said  to  have  occurred  in  Paris  in  the 
week  ending  August  29. 

3  Although  Dr.  Peters  constructed  a  sufficiently  ingenious  hypothesis  for  explaining 
this  epidemic  by  "introduction,"  such  a  view  was,  in  this  instance,  signally  deficient 
in  locally  authenticated  evidence. 


484  ZYMOTIC    1)ISEASES. 

tions  of  South  America  ;  being  especially  severe  at  Buenos  Ayres. 
Central  Eui'ope  also  was  not  free ;  300  deaths  at  least  occurred 
in  Vienna  alone,  in  1873  ;  in  Hungary,  more  than  100,000  deaths. 

China  and  Japan  have  suffered  much  less  frequently  from 
cholera  than  India.  Although  the  earlier  accounts  are  obscure, 
it  appears  that  it  prevailed  in  China  in  1669, 1770,  1817, 1820,  and 
some  other  years,  down  to  1867  ;  and  again  severely  in  1877.  In 
Japan,  it  was  present  at  least  as  early  as  1819 ;  afterwards  at 
intervals  till  1862.  From  that  time  until  1877,  it  was  absent  from 
Japan.  During  the  last-named  year,  a  visitation  of  moderate 
violence  occurred  ;  followed  by  a  still  milder  one  in  1878.  In 
1879,  an  extremely  destructive  epidemic  broke  out  in  Japan,  last- 
ing through  the  whole  summer,  and  having  a  mortality  of  about 
100,000. 

I  take  from  Dr.  Brigham's  treatise  (published  in  1832)  the 
following  table,  of  the  deaths  from  cholera  in  1832,  and  their  pro- 
portion to  population : — 

Population. 

Moscow        .         .         .         350,000 


Petersburg 

Vienna 

Berlin  . 

Hamburg 

London 

Edinburgh 

Glasgow 

Hungary 

Paris    . 

Montreal 

Quebec  . 

New  York 

Albany 


360,000 

300,000 

340,000 

100,000 

1,500,000 

150,000 

180,000 

8,750,000 

800,000 

25,000 

22,000 

200,000 

24,000 


Peaths. 

ECJUAL  TO 

4,690 

in   74 

4,757 

"   74 

11,896 

"  159 

1,401 

"  242 

446 

"  224 

1,223 

"  1228 

72 

"  2033 

395 

"  425 

188,000 

"   46 

20,000 

"   40 

1,250 

"   20 

1,790 

"   12 

2,000 

"  100 

311 

u   77 

Supposing  the  population  of  Philadelphia  to  have  been  at  that 
time  150,000,  this  with  a  little  over  600  deaths,  would  give  a 
proportion  for  our  city  of  1  in  250  of  the  inhabitants.  In  1849 
the  ratio  was  considerably  less.^ 

It  is  an  important  fact  in  the  history  of  cholera,  that  before, 
during,  and  after  the  epidemic  has  visited  a  place,  many  cases, 
greatly  exceeding  in  number  those  of  typical  cholera,  occur,  of 
diarrhcBa,  sometimes  also  with  vomiting,  not  violent,  yielding 
easily  to  treatment.    To  these  the  name  of  cholerine  is  often  given.^ 

Nature  of  Cholera. — "Without  discussing  opinions  at  length,  it 
may  be  asserted  that  cholera  is  not  at  all,  like  our  ordinary 
cholera  morbus,  a  disorder  simply  of  the  stomach  and  bowels. 
Being  clearly  an  acute  systemic  affection,  changes  in  the  blood 
are  proved  to  occur  in  it,  and  may  well  be  believed  to  be  primary  ; 
that  is,  the  morbid  cause  acts  through  the  blood.   But  this  is  not  all. 

1  Moreau  de  Jonnes  estimates  the  number  attacked  as,  in  France,  1  in  300  of  the  popu- 
lation ;  Russia,  1  in  20;  Austria,  1  in  30;  Prussia,  1  in  100;  Poland,  1  in  32 ;  Belgium, 
lin  120;  Great  Britain  and  Ireland,  1  in  131  ;  Holland,  1  in  144;  Germany,  1  in  700. 

2 The  coincidence  or  anticipation  of  cholera  by  epidemic  influenza  and  the  potato 
blight  has  been  several  times  noticed.  But  there  is,  clearly,  no  uniformity  in  any  such 
association. 


CHOLERA.  485 

CuUen  placed  cholera,  in  Jiis  nosology,  in  the  class  neuroses^ 
order  sjmsmi.  Many  medical  observers  (Binaghi,  Loder,  Orton, 
Delpech,  J^izars,  CosLe,  Favell,  C.  W.  Bell,  Greenhow,  G.  John- 
son, etc.)  consider  its  princijjal  ertects  to  be  referable  to  disturbed 
innervation,  involving  chiefly  the  ganglionic  centres  of  organic 
life.  Dr.  Charles  D.  Meigs,  years  ago,  graphically  called  the 
attack  the  "cholera  squeeze."  Velpeau,  of  Paris,  repeated  this, 
"le  mal  vous  tortille.''^  There,  I  think,  is  the  pathology  of 
cholera,  in  one  word.  As  Dr.  C.  W.  Bell  says,  it  is  not  an  adyna- 
mic, but  a  dynamic,  or  sthenic,  collapse. 

The  heart,  its  left  side  at  least,  is,  after  death,  contracted. 
The  pulmonary  artery  and  its  branches  are  narrowed,  making  the 
lungs  pale  and  aneemic.  The  gall-bladder  is  full  of  bile,  but  the 
duct  is  spasmodically  closed  and  detains  it  there.  The  urinary 
bladder  is  shrunken  to  half  its  size  or  less.  The  blood-vessels  of 
the  whole  alimentary  canal  press  rigidly  upon  their  contained 
fluid,  and  force  its  serum  out  into  the  stomach  and  bowels ; 
whence  it  is,  by  spasmodic  ejections,  thrown  out.  The  very  skin  ' 
is,  by  its  involuntary  muscular  fibres,  as  well  as  by  vascular 
constriction  everywhere,  drawn  tightly  and  closely  upon  the 
body.  The  voluntary  muscles  suffer  with  cramps.  All  is  cramp, 
cramp,  within  and  without.  The  brain  is  almost  in  anaesthesia 
during  the  collapse — no  delirium,  but  apathy — as  from  cerebral 
anaemia.  The  blood  so  compressed  grows  thick  as  tar — it  scarcely 
flows,  is  not  aerated,  and  cyanosis  follows  ;  it  is  detained  in  the 
capillary  and  venous  networks  of  the  interior  organs,  in  which 
congestion  is  found  after  death. 

Cholera  is,  then,  I  say,  a  poison-spasm  ;  a  ganglionic  tetanus. 

Causation. — As  to  this,  all  cannot  yet  be  known.  But  it  is  clear 
that  cholera  must  have  a  specific  material,  migratory  cause.  I 
agree  with  Dr.  G.  B.  Wood,  Dr.  Austin  Flint,  Dr.  Snow,  of  Provi- 
dence, and  some  foreign  authorities,  for  example  the  late  Dr. 
Southwood  Smith,  "the  father  of  modern  sanitary  reform,"  in 
believing  that  cholera  is  not  inrsonally  contagious. 

My  theory  is  as  follows  :  that  the  cause  of  cholera  is  a  (yet 
undiscovered)  protozoon  or  microphyte,  of  extreme  individual 
minuteness  ;  which  on  entering  the  human  body,  affects  it  as  an 
organic  poison.'     That  the  varying  quantity  or  number  of  these 

1  Hallier  of  Jena,  Klob  of  Vienna,  and  Thome  of  Cologne,  have  asserted  the  discovery 
of  peculiar  funsi  in  cholera  dejections.  Thome  gives  the  name  of  "cylindro-tsenium  " 
to  one  form.  Hallier  calls  the  fungus  "  urocystis,"  and  ascribes  it  to  the  rice-plant.  Tliis 
view  is  opposed  by  Berkeley,  a  distinguished  cryptogamic  botanist.  Prof.  H.  C.  Wood 
energetically  disputes  it.  See  American  Journal  of  Med.  Sciences,  Oct.,  1868,  p.  333. 
Assistant  Surgeon  T.  R.  Lewis,  of  the  British  army  in  India,  gives  important  facts 
against  Hallier's  theory.  See  "Report  on  Microscopic  Objects  found  in  Cholera  Evac- 
uations. Calcutta.  1870."  E.  Semmer  (Virchow's  Arcliiv.,  vol.  i.,  part  i.,  pp.  158-160) 
asserts  partial  confirmation  of  Hallier's  views,  by  the  production  of  the  milzbrand  or 
splenic  cattle-disease,  upon  the  injection  of  fungus-spores  and  micrococcus-cells,  culti- 
vated from  the  blood  of  animals  having  that  disease.  Loesch,  of  St.  Petersburg, 
reports  the  observation  of  niuUiludes  of  cercomonads  in  recent  choleraic  dejections. 
Not  impossibly,  such  minute  organisms,  even  though  not  peculiar  to  the  disease,  may 
exert  a  morbid  influence  by  their  number.  (St.  Petersburg  Med.  Journal,  1871.)  Dr. 
Cunningham  of  India,  reported  (1880)  an  investigation  of  the  stools  of  cholera  patients, 
in  which  he  found  ci'rtain  parasitic  monads,  etc.,  to  which  he  gives  the  name  jirolo- 
myxomyces  coprinmrius ;  but  he  does  not  believe  tliera  to  be  causn/ire  of  cholera.  They 
are  often  present  in  the  intestines  of  persons  not  having  that  disease  ;  as  well  as  in 
those  of  other  animals. 

41* 


486  ZYMOTIC    DISEASES. 

organisms  may  in  different  cases  account  (along  with  individual 
predispositions  and  exposures)  for  the  unequal  violence  of  differ- 
ent epidemics  ;  as  in  the  case  of  trichinosis.  Choleraic  diarrhoea, 
or  cholerine,  so  frequent  before  as  well  as  during  and  after  the 
prevalence  of  cholera,  may  in  some  instances  at  least  be  explained 
by  the  action  upon  the  alimentary  canal  only,  of  a  minimum 
quantity  of  the  cause.  The  dreadful  fatality  of  some  Indian 
seasons,  is  on  the  same  view  referred  to  an  extreme  accumulation 
of  it. 

A  most  important  part  of  the  theory  is,  further,  that  which 
concerns  promotive  causation.  What  conditions  favor  and  main- 
tain in  life,  multiplication,  and  migration,  this  ens  primalis  f 

All  the  facts  answer,  I  believe,  that  animal  matter  in  a  state  of 
rapid  and  foul  decomposition,  putrefaction,  along  with  moderately 
high  (not  the  highest)  temperature,  and  ordinary  moisture,  will 
afford  those  conditions  ;  and  thatnothing  else  is  required  to  explain 
the  whole  history  of  the  propagation  and  extension  of  cholera. 
Nothing,  I  mean,  but  the  admission  of  the  existence  of  the  pro- 
tozoon,  or  protophyton,  which  in  germs  or  in  maturity,  or  both, 
may  fly  "on  the  wings  of  the  wind  ;"  or  be  conveyed  to  less  dis- 
tances by  water ;  and,  with  these  the  above-named  conditions  of 
its  vital  maintenance,  as  its  food  and  "habitation." 

It  is,  in  my  mind,  obvious  that  this  theory  will  explain  all  the 
facts.  I  believe,  also,  that  some  well-known  facts  can  be  exjDlained 
by  it  alone.  Such  are  the  facts  which  account,  by  the  annual  inun- 
dations, the  crowding  of  the  great  fairs,  the  throwing  of  bodies 
into  the  river,  and  the  inconceivable  filth  of  the  inhabitants,  for 
the  persistent  residence  of  cholera  in  the  Gangetic  delta,  while 
everywhere  else  it  is  only  an  occasional  visitant. 

In  Europe  and  the  United  States,  as  well  as  in  India,  influences 
belonging  to  closely  aggregated  communities  have  always  been 
observed  to  display  a  power  to  propagate  cholera.  It  comes  most 
often,  stays  longest,  and  is  most  destructive,  in  the  densest  and 
filthiest  cities,  and  in  the  worst  quarters  of  those  cities. 

Very  important  testimony  exists  as  to  the  influence  of  the 
drinking-water  of  localities.  Dr.  Snow,  of  England,  asserted  the 
theory  that  this  was  the  almost  universal  medium  of  its  propa- 
gation. This  has,  to  my  belief,  been  shown  to  be  quite  insuf- 
ficient. But  all  such  testimony  is  still  available  in  regard  to  the 
propagating  and  extending  power  of  animal  contamination.  Thus, 
Bethlehem  Hospital,  supplied  by  an  artesian  well,  had,  in  1849, 
among  400  inmates,  no  case  of  cholera.  It  was  the  only  large 
lunatic  hospital  in  London  which  escaped ;  as  it  was  the  only 
one  supplied  with  spring  water.  In  the  district  of  London  sup- 
plied from  the  Thames  above  the  entrance  of  the  sewers,  the  mor- 
tality ranged  from  8  to  33  in  10,000  of  the  inhabitants ;  in  those 
supplied  from  below  the  entrance  of  the  sewers,  from  28  to  205 
of  the  same  number. 

"  In  this  country.  Dr.  James  "Wynne's  report'  affords,  upon  almost 
every  page,  matter  of  exactly  the  same  purport  as  the  above.  In 
St.  Louis,  Louisville,  Buffalo,  Kew  York,  Philadelphia,  Boston, 

1  Presented  to  Parliament,  and  published  in  1852. 


CHOLERA.  487 

etc.,  similar  facts  were  rocor<led.  It  is  unnecessary  to  extract 
thcni,  tlicy  are  now  so  familiar  and  so  commonly  accepted. 

Dr.  1).  B.  Simmons,'  of  Japan,  asserts  that  the  occurrence  of 
cholera  in  that  country,  much  more  often  and  more  destructively 
than  in  China,  may  be  explained  by  the  use  in  Japan  of  latrines 
sunk  in  the  ground,  poisoning  the  ground-water;  while  in  China 
the  excreta  are  deposited  in  boxes,  whose  contents  are  carried 
away  daily  and  used  as  manure. 

But  the  assertion  that  contamination  of  drinking-water  is  the 
onhi  medium  for  the  propagation  of  cholera  cannot  be  sustained. 
In  India,  for  example.  Dr.  Sutherland,  statistical  officer  to  the 
Inspector-General,  reports  that  the  statements  often  made  else- 
where concerning  drinking-water  "cannot  be  said  to  apply  to  the 
causation  of  the  disease  as  it  appeared  in  this  country  in  1SG7. " 
Dr.  Bryden,  sui'geon  in  the  Bengal  army,  says,  "I  have  anx- 
iously sought  for  evidence  of  the  highly  poisonous  character  of 
cholera  evacuations,  with  an  unprejudiced  mind,  I  do  not  go  so 
far  as  to  say  that  the  evidence  is  against  the  presence  of  cholera 
germs  in  the  evacuations.  I  think  it  highly  probable  that  latrines 
are  occasionally  infected,  especially  hospital  latrines." 

Prof.  Pettenkofer,  of  Munich,  rejects  absolutely  the  (now  quite 
current)  theory  of  the  special  extension  of  cholera  by  means  of 
the  stools  of  patients  contaminating  drinking-water.  Dr.  E.  M. 
Estrazulas-  has  presented  important  testimony  showing  that  an 
epidemic  of  cholera  in  Paraguay,  beginning  in  1866  (continuing 
as  an  endemic  for  three  years),  could  not  have  been  imported  by 
means  of  human  intercourse,  through  ships  or  otherwise ;  the 
peculiar  circumstances  of  the  war  with  Brazil  making  this  impos- 
sible. At  least,  it  is  certain  that  no  quarantine,  or  other  system 
of  restrictions,  could  have  done  more,  if  so  much,  to  prevent  its 
conveyance. 

The  instances  of  apparent  transmission  of  cholera  by  persons, 
which  are  quite  exceptional,  even  if  we  admit  a  hundred  or  more 
authentic  examples,  are,  as  I  believe,  to  be  explained  on  the  prin- 
ciple of  fomites;  of  occasional,  very  rare,  carrying  of  the  material 
cause  of  the  disease,  the  "  germs  "  of  it,  in  clothing,  merchandise, 
or  by  the  person  of  a  human  being ;  as  one  might  carry  skippers 
on  a  piece  of  cheese  in  his  pocket,  or  a  paper  of  seeds  in  his 
carpet-bag. 

All  of  Pettenkofer's  and  Thiersch's  observations  in  regard  to 
subsoil  accumulation  and  transit,  and  fecal  fermentation  after 
discharge,  range  themselves  naturally  under  the  one  general  fact 
which  they  exemplify,  viz.,  that  aniinal  decomposition  is  the  great 
'promotke  cause  of  cholera;  to  which  heat  and  moisture,  etc.,  are 
merely  adjuncts. 

But  that  which  suggested  first  to  me  this  opinion  was,  the  sin- 
gular history  of  the  outbreak  at  Columbia,  Lancaster  County, 
Pennsylvania,  in  September,  1854.  Cholera  had  never  visited 
that  town  before.  It  is  not  large  or  populous,  has  a  rural  site 
on  the  Susquehanna,  and  is  not  built  densely  enough  to  exclude 
malarial  fevers.     AVhy  should  it  have  cholera  at  all? 

1  Cholera  Epidemics  in  Japan ;  Shang-hai,  1879. 
-  Amer.  Journal  of  Med.  Sciences,  July,  1873. 


488  ZYMOTIC    DISEASES. 

Visiting  the  town  with  other  physicians  during  the  epidemic, 
I  learned  tliat  an  exceeding  drought  liad  reduced  the  channel 
of  the  river  to  an  unusually  low  ebb,  and  that,  in  its  bed,  a  short 
space  above  the  town,  a  number  of  carcasses  of  sheep  and  other 
animals,  thrown  from  the  railroad  trains,  etc.,  were  putrefying 
rankly  in  the  sun.  A  reservoir,  which  supplied  many  of  the  peo- 
ple with  drinking-water,  was  filled  from  the  river  not  far  from 
that  spot,  and  the  wind  blew  from  it  directly  over  the  town.  The 
first  subsidence  in  the  disease,  we  were  afterwards  told,  attended 
a  decided  change  in  the  wind. 

At  Pittsburg,  shortly  after  the  above  events,  a  similar  epidemic 
occurred.  A  gentleman  on  a  visit  to  that  locality  not  many  days 
before  the  disease  broke  out,  informed  me  that  the  same  condition 
of  the  river  existed  there,  with  a  like  abundance  of  accumulated 
putreff/ing  animal  matter  exposed  to  the  sun. 

In  Rhode  Island,  in  the  autumn  of  the  same  year,  I  was 
informed  that  the  local  existence  of  cholera,  in  a  few  spots  other- 
wise very  healthy,  might  be  traced,  in  coincidence  at  least,  with 
a  practice  not  uncommon  along  the  shore  of  the  sea  or  bays,  of 
dragging  up  fish  in  quantities  by  nets,  and  spreading  them  out  to 
rot  for  manure. 

Prevention. — Quarantine  is  urged  by  many,  in  this  country  as 
well  as  in  Europe,  to  exclude  cholera.  Is  it  available?  Will  it 
do  any  good  ?  I  say  no.  Theoretically,  if  the  views  advocated 
in  the  preceding  pages  are  correct,  it  falls  to  the  ground,  of 
course.     But,  more  than  that,  it  never  has  succeeded. 

Dr.  Alison,  of  Edinburgh,  wrote  thus  in  1854 :  "It  is  a  fact  that 
cholera  has  made  its  way,  not  uniformly,  but  very  generally,  in 
spite  of  cordons  and  quarantine  regulations.'''' 

Dr.  Gavin  Milroy,  one  of  the  ablest  and  most  industrious  sani- 
tarians of  our  time,  published,  about  the  same  year,  an  essay 
with  this  title:  "  The  Cholera  not  to  he  Arrested  by  Quarantine.'''' 
M.  Cazalas,  Inspector  of  the  Sanitary  Department  of  the  French 
army,  after  full  inquiry,  has  declared  that  cholera  is  non-con- 
tagious, and  that  its  preventive  should  be  not  quarantine,  but 
an  international  sanitary  code.  Dr.  A.  J.  Payne,  of"  the  Bengal 
Medical  Service,  wrote  (1869)  thus:  "In  a  large  majority  of  the 
examples  in  which  the  efficacy  of  isolation  is  affirmed,  it  is  clearly 
provable  that  isolation  cannot  have  had  any  influence  on  the 
events,  and  in  no  single  instance  has  its  necessity  or  usefulness 
been  demonstrated."  Dr.  Bryden,  of  the  Sanitary  Commission, 
India, ^  says  that  "the  geographical  distribution  of  the  disease 
would  not  have  been  different  had  no  Hurdwar  gathei"ing  taken 
place."  He  also  speaks  of  a  '■''cholera  wave.,''''  witli  definite  direc- 
tions of  progress,  and  adds  that  "  experience  in  India  is  certainly 
on  the  whole  opposed  to  the  doctrine  that  human  intercourse  is 
the  only,  or  even  a  principal,  cause  of  the  spread  of  the  disease 
over  any  large  area  of  country." 

1  Report  on  the  Cholera  of  1866-68  in  Bengal,  etc.  In  a  Report  published  in  1878, 
Bryden  reasserts  his  conviction  thus:  '''Human  intercourse,  giving  the  widest  scope  to 
the  signification  of  the  term,  cannot  pretend  to  account  for  any  fundamental  phenom- 
enon displayed  during  the  progress  of  epidemic  cholera:  and  therefore  I  assert  the 
theory  to  be  radically  untrue  as  applied  to  the  behavior  of  cholera  in  India," 


CTTOLERA.  489 

Petlenkofer,  the  leading  adv'ocate  of  the  hypothesis  that  cholera 
is  didused  by  the  intiucuee  of  an  organic  poison  contained  in 
water,  has  ainiouneed  his  conviction  that  local  sanitary  measures 
are  much  niore  rc^liable  for  its  prevention  than  quarantine.  Sir 
W.  Jenner  has  expressed,  the  same  opinion.' 

Quarantine,  if  sound  in  theory  even,  could  not  avail,  never  has 
availed  in  practice.  Its  infraction  for  smuggling  and  other  in- 
ducements is  everywhere  constant  and  notorious ;  this  cannot  he 
pi-evented.  Macaulay  (History  of  England,  vol.  v.,  p.  52)  states 
that  when  a  contraband  trade  was,  in  the  time  of  William  III., 
carried  on  between  France  and  England  on  the  south-eastern  coast, 
"it  was  a  common  saying  among  the  inhabitants,  that  if  the  gal- 
lows were  set  up  every  quarter  of  a  mile  along  the  coast,  the  trade 
would  still  go  on  briskly." 

One  might  think  that  the  history  of  hlocJcade-riinning  during 
the  late  civil  war  in  this  country  might  afford  ample  illustration 
and  confirmation  of  this.  Vain,  indeed,  would  be  the  attempt 
to  close  our  coast  against  the  introduction  of  cholera,  were  it  as 
contagious  as  small-pox,  or  as  plague  was  once  imagined  to  be,'^ 

The  evils  of  quarantine  are  great,  almost  incalculable.  Sir 
John  Bowring,  speaking  in  the  House  of  Commons  in  1841,  gave 
it  as  his  belief  that  the  losses  from  quarantine  in  the  Mediter- 
ranean alone  were  not  less  than  two  or  three  millions  sterling  a 
year. 

But  wliat  if,  instead  of  preserving,  quarantine  actually  involves 
sacrifice  of  life  f  !N'o  doubt  this  has  many  times  occurred.  With 
yellow  fever  the  quarantine  epidemic  in  New  York  harbor,  some 
years  ago,  exemplified  this.  In  various  quarters  reports  of  trav- 
ellers show  the  miseries  and  dangers  of  the  lazaretto,  and  of  the 
confinement  on  the  vessels  detained. 

What  more  do  we  need  than  the  instance  of  the  steamer  Eng- 
land, at  Halifax  ?  Eorty  passengers,  one  account  says  fifty  (out 
of  1202),  died  on  this  vessi'l  during  the  voyage.  She  was  prohib- 
ited from  entering  port ;  all  were  detained  on  board,  and  by 
April  14,  18(')6,  130  more  deaths  occurred!  In  all,  159  died  while 
in  quarantine.  If  the  eleven  hundred  and  fifty  passengers  had 
been  landed  and  scattered,  I,  for  one,  doubt  the  occurrence  of  the 
disease  in  a  dozen  of  their  number,  especially  as  it  was  reported 
as  altogether  confined  to  the  steerage. 

Were  such  measures  sure  to  preserve  from  the  epidemic  the 
whole  people  of  a  continent,  a  hecatomb  like  this  might  find  ex- 
cuse. In  the  face  of  facts  I  regard  it  as  a  barbarity.  Pelissier, 
in  Algiers,  was  thought  a  monster  for  suffocating  a  band  of  guer- 
rillas in  a  cave ;  but  what  is  this  case  of  the  England  more  like, 
except  in  motive?  It  is  closing  up  hundreds  of  people  for  death, 
as  though  one  jnight  lock  the  doors  and  bar  the  windows  against 
all  escape  of  a  thousand  people  from  a  burning  church  ;  such  as 
that  of  which  we  read  so  harrowing  an  account,  some  time  back, 
in  South  America. 

But  it  will  be  asked.  Would  you  abolish  all  quarantine — abandon 

1  Address  before  the  Epidemiological  Society,  1866;  pul)lished  1869;  p.  53. 
-  The  Governor  of  Eupatoria  is  said  to  havn  wished  the  British  aad  t'rench  troops  to 
undergo  quarantine  at  the  opening  of  the  Crimean  war. 


490  ZYMOTIC    DISEASES. 

all  inspection  of  shijys  whatever  ?  No ;  I  would  not.  But  I  would 
abandon  altogether  the  current  theory  of  quarantine,  as  against 
cholera  most  particularly. 

Ships  should  be  inspected  on  approaching  ports,  because  they 
may  have  unsanitary  conditions  intensified  in  them  on  a  scale 
sufficiently  large  to  be  important.  This  is,  or  should  be,  a  part 
of  sanitary  police.  Nor  should  it  (and  here  is  a  great  point  of 
difterence)  include  any  restriction  of  persons;  at  the  most,  longer 
than  enough  for  cleansing  of  the  body  and  of  the  clothing,  and 
purification  of  merchandise  by  fresh  air,  and  possibly  by  some 
disinfecting  process  in  certain  cases. 

I  insist  that  Sanitary  Police  includes  the  sum  total  of  avail- 
able measures  for  the  prevention  of  cholera  in  any  place. 

On  this  ground,  the  means  required  are  obvious  and  familiar. 
The  thorough  and  frequent  cleansing  of  all  streets,  alleys,  courts, 
wharves,  and  vessels,  private  and  public  buildings,  and  empty 
lots ;  the  abatement  of  all  nuisances ;  daily  removal  of  oft'al ; 
efficient  sewerage  ;  and  conservancy^  i.e.,  the  cleansing, ventilation, 
and  disinfection  of  cesspools  and  water-closets.  Among  all  signs 
of  danger  of  the  location  of  cholera,  none  is  more  significant  than 
the  privy  odor.  Let  it  be  everywhere  annihilated.  Lime,  char- 
coal, dry  earth,  burning  sulphur,  chloride  of  lime,  Labarraque's 
chloride  of  soda,  liquid  coal-tar,  chloride  of  zinc,  and  sulphate 
,  of  iron  are  the  most  available  of  disinfectants. 

The  fresh  white-washing  of  cellars  is  useful ;  thorough  ventila- 
tion and  drying  of  them,  and  of  all  parts  of  habitations,  still  more 
so.  Chloride  of  lime  may  be  placed  in  a  saucer  in  any  suspected 
room  or  other  locality  in  a  house.  The  same  in  the  solid  form, 
or  solution  of  green  vitriol,  may  be  thrown  daily  into  a  foul  privy ; 
and,  during  cholera  time,  especially  in  the  case  of  patients  with 
the  disease,  every  water-closet  and  vessel  used  may  and  should 
be  disinfected  constantly  by  a  dilute  solution  of  chloride  of  zinc, 
chloride  of  soda,  permanganate  of  potassium,  or  carbolic  acid. 
The  immediate  removal  of  all  discharges  from  the  sick-room, 
their  disinfection  and  transportation  to  the  safest  possible  place 
of  elimination,  are  to  be  imperatively  maintained.  All  foul 
clothing  must  be  promptly  washed,  or,  if  very  bad,  disinfected  or 
burned. 

These  precautions  have  been  proved  to  be  capable  of  essen- 
tially limiting  and  mitigating  the  prevalence  of  epidemics. 

Clapton,  Burq,  and  some  others  have  asserted  a  remarkable 
antagonism  between  the  effects  of  copjper  on  the  human  system 
and  the  susceptibility  of  cholera.  M.  Burq  states  that,  during 
the  epidemic  of  1865-66  in  France,  only  one  in  1270  workers  in 
copper  was  attacked ;  of  workers  in  iron  and  steel,  one  in  209 ; 
and  of  those  engaged  on  other  metals,  one  in  178, 

Personal  Prevention.— One  principle  will  suffice  here :  to  keep 
the  system  at  par ;  neither  above  its  level  of  excitement,  nor  below 
that  of  its  due  strength. 

For  this,  regularity  of  life  is  required  in  work,  diet,  mental 
movements,  and  all  indulgences.  The  popular  errors  most  com- 
mon are,  one,  to  suppose  that  living  on  rice  or  rice-water,  avoid- 
ing fruits  or  vegetables,  etc.,  will  be  preventive  ;  another,  to  think 


CHOLERA.  491 

constant  alcoholic  stimulation  beneficial  for  that  end.  Both  are 
cerlainh/  tvrong. 

In  li^:5"2  and  1R40,  the  late  Dr.  Joseph  Hartshorno,  then  in  very 
larjijc  practice,  allowed  in  his  family  all  its  usual  variety  of  food  : 
boiled  corn,  peaches,  watermelons,  cantaloupes,  etc.,  everythinf]j 
but  cucumbers;  and  no  cholera  resulted  from  the  liberty.  My 
own  subsequent  experience  has  justified  the  practice.  Of  course 
care  is  always  needed  as  to  qualitynud  quantiti/. 

Among  those  most  likely  to  die  when  attacked  by  this  dis- 
ease, the  drunkard  stands  first,  according  to  all  records.  Xor  is 
he  one  whit  less  apt  to  be  attacked  than  others.  Temperance  in 
all  things  is  essential  to  safety  during  epidemics  of  every  kind. 

Treatment. — To  discuss  all  the  modes  of  management  proposed 
for  cholera  would  occupy  too  much  space.  I  shall  merely  enu- 
merate those  which  have  attracted  the  most  attention ;  and  then 
give  my  view  as  to  what  is  so  well  sustained  as  to  be  worthy  of 
further  trial  and  confidence. 

1.  Bleeding'. — This  was  largely  practised  in  India,  in  1818-182.5, 
by  Corbyn,  Scot,  Annesley,  and  others.  Without  entering  upon 
any  argument  about  it,  I  will  simply  say  that  (as  Dr.  Brigham's 
quotations  show)  as  many  positive  facts  have  been  asserted  on 
behalf  of  the  success  of  bloodletting  as  of  any  other  remedy  in 
cholera.'  My  father  bled  in  several  cases  in  1832,  and  had  con- 
fidence in  the  treatment,  as  "  the  most  effectual  anti-spasmodic.'''' 
In  1849  I  bled  in  one  case  (a  boy  of  twelve  years  of  age) 
in  incipient  collapse.  The  blood  at  first  was  thick  and  black 
as  tar ;  in  a  few  minutes  it  flowed  more  freely,  and  the  patient 
recovered.  I  confess  that  the  only  thing  which  makes  it  unlikely 
that  I  will  ever  try  or  advise  the  repetition  of  this  practice  is  the 
want  of  courage  to  stem  the  overwhelming  tide  of  professional 
and  popular  opposition  now  existing  against  it.  In  this  timidity 
I  may  be  wrong ;  if  so,  another  generation  may  afford  the  demon- 
stration of  what  is  right  in  such  a  way  that  no  one  can  gainsay  it. 

2.  Calomel. — This,  too,  was  an  old  East  Indian  remedy.  Sug- 
gested by  the  almost  universal  absence  of  bile  in  the  discharges, 
which  was  thought  to  indicate  the  need  of  stimulation  of  the 
torpid  liver,  it  has  been  more  largely  given  than  any  other  med- 
icine in  cholera. 

Unhesitatingly  I  hold  the  opinion  that  calomel  is  of  no  earthly 
use  in  cholera.  The  argument  in  its  favor,  from  the  absence  of 
bile  in  the  stools,  is  rebutted  by  the  fact  of  its  abundance  in  the 
gall-bladder ;  while  the  clinical  experience  quoted  for  its  success 
is  accounted  for  by  the  addition  to  it  almost  always  of  opium  in 
the  prescription.  ISTor  is  the  amount  of  success  with  it,  even  then, 
great.  Such  is  Dr.  Gull's  conclusion,  based  upon  the  examina- 
tion of  a  great  mass  of  evidence,  given  in  his  report.^ 

Dr.  Ayre,  a  British  practitioner  of  some  note,  gave  prominence 
to  a  modification  of  the  old  calomel  treatment  (in  which  twenty 

1  In  1861,  Surgeon  G.  R.Playfair,  at  Af;ra,  India,  found  venesection  to  about  8  ounces, 
followed  by  stimulants  (especially  cbloroform),  the  most  successful  treatment.  He 
reports  more  than  77  per  cent,  cured  of  genuine  cholera. — Ind.  Med.  Journal,  September, 
186G,  p.  275. 

*  Report,  etc.,  of  Drs.  Baly  and  Gull,  already  cited. 


492  ZYMOTIC    DISEASES. 

grains  were  sometimes  given  at  once),  by  prescribing  a  grain  of 
calomel  every  five  minutes  during  the  attack. 

3.  Saline  Treatment. — Dr.  Stevens,  of  Jamaica,  proposed  this, 
upon  the  view  that  the  main  pathological  element  in  cholera  is 
the  loss  of  salts  from  the  blood  in  the  discharges.  After  the 
general  failure  of  saline  solutions  (of  common  salt,  carbonate  and 
phosphate  of  sodium,  etc.),  given  by  the  mouth,  had  been  con- 
ceded. Dr.  Mackintosh,  of  Edinburgh,  and  others  tried  the  method 
of  injection  into  a  vein  (half  an  ounce  of  common  salt,  and  four 
scruples  of  bicarbonate  of  sodium,  dissolved  in  ten  pints  of  water, 
at  105°  to  120°  Fahrenheit).  Under  this  plan,  resorted  to  dur- 
ing collapse,  of  156  patients  in  Dr.  Mackintosh's  hands,  only  25 
recovered.  Kemarkable  improvement,  almost  like  a  resurrection, 
appeared  in  several,  who  afterwards  fell  again  into  collapse,  and 
died.  The  suggestion  has  been  recently  made,  that  it  may  have 
been  the  temperature  of  the  injected  liquid  which  produced  the 
benefit,  so  promising,  and  yet  so  transient. 

In  this  place  we  may  mention  also  the  use  by  Dr.  E.  M.  Hod- 
der,^  of  Toronto,  of  the  transfusion  of  milk,  fourteen  ounces  at  a 
time,  into  a  vein,  during  the  collapse.  He  reports  the  recovery 
of  two  cases  out  of  three  under  this  practice.  The  transfusion 
of  blood  would  appear  to  be  more  reasonable  for  trial.  Kalisher'^ 
has  reported  two  successful  cases  of  transfusion  of  blood  in 
cholera. 

4.  Eliminative  Treatment. — Dr.  George  Johnson,  of  London, 
has  urged  this  with  especial  vigor.  The  castor-oil  medication  of 
cholera  owes  its  trial  to  him.  His  lectures  on  the  pathology  and 
treatment  of  the  disorder  give  a  full  and  very  intelligent  exposi- 
tion of  his  views.  A  prominent  idea  with  him  is  that  the  general 
collapse  is  due  especially  to  ansemia  of  the  lungs,  owing  to 
spasmodic  contraction  of  the  pulmonary  artery  and  its  branches. 
I  regard  this  as  only  a  part  of  the  universal  arterial  (and  other) 
involuntary  muscular  spasm,  belonging  to  what  I  have  called  the 
ganylionic  tetanus  of  the  collapse.  But  the  essential  feature  of 
Dr.  Johnson's  pathology  is  the  opinion  that,  the  disease  being 
toxsemic,  a  morbid  poison  exists,  which  must  be  eliminated  from 
the  blood  ;  and  that  the  discharges  are  the  media  of  this  elimina- 
tion. Therefore,  the  vomiting  and  diarrhoea  are  salutary  or 
relieving,  and  ought  to  be  rather  encouraged  than  checked.  Pie 
goes  even  so  far  as  to  repudiate  the  commonly  accepted  belief, 
that  "premonitory  diarrhoea"  or  "cholerine"  ought  to  be 
checked,  considering  it  a  fallacy  to  assert  that  those  who  are 
relieved  of  such  symptoms  by  mild  treatment  are  really,  or  would 
have  been,  cases  of  cholera  at  all. 

I  am  entirely  unable,  from  observation  or  reflection,  to  assent 
to  these  views.  They  have  very  few  advocates  or  supporters, 
besides  the  distinguished  physician  whose  name  and  ability  have 
commanded  for  them  careful  consideration.  It  is  true  that  patients 
have  died  of  cholera  without  vomiting  or  purging.  1  saw  in 
1849  a  woman  in  collapse  (from  which  she  recovered)  for  several 

1  London  Practitioner,  January,1873. 

2  Inaug.  Dissertation,  Berlin,  1873. 


CHOLERA.  493 

hours  without  either  ;  and  many  such  cases  are  on  record  ;  though 
in  some,  after  death,  the  intestines  have  been  found  to  be  dis- 
tended with  rice-water  hquid.  But  the  checking  of  the  dis- 
charges is  ahnost  always  the  sign  of  improvement  and  recovery 
of  the  patient.  And  we  cannot,  on  Dr.  Johnson's  dictum,  set 
aside  or  (juasli  all  the  accumulated  evidence,  in  Europe  and  in 
this  country,'  which  shows  that  it  is  desirable  and  important  to 
check  all  watery  diarrhtxas  in  cholera  times — such  fluxes  having 
been  proved  to  be  often  premonitory  of  cholera  attacks. 

5.  Ice  to  the  Spine. — Dr.  John  Chapman's  ice-bags  once  threat- 
ened to  become  the  "  pathy  "  or  therapy  of  the  day,  with  some  who 
are  zealous  and  venturesome  in  experimental  practice.  Upon 
reasons  of  a  physiological  nature,  not  appropriate  for  discussion 
here,  I  disbelieve  altogether  in  the  theory  of  his  therapeutics. 
As  ice  is  useful  when  internally  given  in  cholera,  it  may  be  safe 
and  beneficial  when  applied  to  the  spine.  Not  having  seen  it 
tried,  I  am  not  prejiared  to  deny  the  possibility.  It  is  one  of 
the  experiments  to  consider,  in  so  desperate  a  disease.  But  if  it 
should  prove  useful,  I  should  explain  that  result  quite  otherwise 
than  Dr.  Chapman  has  done,  in  part  at  least. 

6.  Sulphuric  Acid. — Dr.  Cox,  of  England,  afterwards  Mr.  Bux- 
ton and  Dr.  Fuller,  and  Dr.  Jules  Worms,  of  Paris,  have  especially 
recommended  dilute  sulphuric  acid  in  all  stages  of  cholera. 
Many  others  especially  report  well  of  its  action  in  the  premonitory 
diarrhoea.  Such  an  action  would  comport  perfectly  with  the  view 
1  have  taken  of  the  organic  nature  of  the  poison  of  cholera  ;  sul- 
phuric acid  being  so  potent  a  destroyer  of  everything  organic, 
except  such  mirahilia  as  the  Acarus  Crossii. 

Dr.  Worms's  treatment  (based  on  results  in  238  cases  of  cholera, 
and  150  of  cholerine,  in  1865)  is  as  follows  :  For  prodromic  diar- 
rhoea, he  makes  a  "mineral  lemonade,"  of  about  half  a  drachm 
of  concentrated  sulphuric  acid  to  a  pint  or  more  of  sweetened 
decoction  of  salep  (arrowroot  would  do  as  well).  The  patient  is 
to  take  of  this  every  hour  a  wineglassful  till  relieved.  A  similar 
practice,  as  I  am  informed  by  Dr.  Curtin,'^  was  found  useful  among 
the  inmates  of  the  Philadelphia  Almshouse,  in  18G6. 

For  confirmed  cholera,  the  patient  being  kept  in  complete  repose, 
there  is  administered  every  half  hour  a  glass  of  a  similar  lemon- 
ade, of  the  strength  (about)  of  a  drachm  to  the  pint ;  ice  and 
wine  also  being  allowed  ad  libitum. 

7.  Opium  in  large  doses. — This  practice  once  had  many  advo- 
cates ;  now  they  are  few.  Prof.  Austin  Flint,  of  New  York,  is 
one  of  them  ;  at  least  morjjhia  is  advised  by  him,  in  full  dose, 
repeated  if  required.  A  great  deal  of  evidence  of  the  insufRciency 
of  such  a  plan  has  been  published  ;  although  it  is  not  iwrse  than 
several  other  methods.  The  secondary  fever  is  apt  to  be  more 
severe  and  more  often  fatal  after  treatment  of  the  attack  by  large 
doses  either  of  opiates  or  stimulants.  Large  quantities  of  brandy 
have  been  often  used,  with  no  good  results. 

Statistics  are  given,  as  follows,  of  the  results  of  some  of  the 

1  See  Lectures  on  Cholera,  by  Prof.  A.  Clark,  of  New  York  ;  Report  to  the  Eoyal  Col- 
lege of  Physicians,  1854  ;  also,  Madin,  Briquet  and  Mignot,  etc. 

2  See  Philada.  Med,  Times,  July  12, 1873. 

42 


494 


ZYMOTIC    DISEASES. 


most  common  modes  of  practice  in  cholera,  by  practitioners  in 
Great  Britain,  as  reported  to  the  ''  Treatment  Committee  of  the 
Medical  Council  of  the  Board  of  Health,"  1854-1855. 


Taking  all  grades  of  the  disease,  the  deaths  were- 

With  Eliminants  .         . 

Stimulants 

Calomel  and  Opium    .... 
Chalk  and  Opium       .... 

Of  collapsed  cases,  the  mortality  was — 

With  Calomel  and  Opium    . 
Larger  doses  of  Calomel 
Salines 

Chalk  and  Opium 
Calomel,  small  doses 
Castor  Oil    . 
Sulphuric  Acid   . 


Per  cent. 

71.7 
54.0 
36.2 
20.3 


Per  cent. 

59.2 
60.9 
62.9 
63.2 
73.9 
77.6 
78.9 


Much  is  uncertain  obviously,  in  such  statistics,  without  further 
account  of  dosage,  circumstances,  etc.  But  this  seems  to  follow ; 
that  neither  treatment  has  much  to  boast  of  success. 

8.  Treatment  by  antispasmodics  and  mild  stimulants,  in  small 
doses  at  short  intervals;  with  ice/  and  external  frictions,  etc. — 
My  experience  with  cholera  has  led  me  to  give  this  mode  of  treat- 
ment the  preference  over  all  others.  I  first  met  with  it  in  the 
practice  of  the  late  Prof.  W.  E.  Horner,  in  1849.  Dr.  Horner 
gave  a  mixture  of  chloroform,  camphor,  and  laudanum,  in  small 
doses,  every  five  minutes ;  each  dose  being  followed  by  a  piece 
of  ice.  I  altered  Prof.  Horner's  mixture  to  a  tincture,  for  better 
preservation ;  adding  some  minor  adjuvants.  This  recipe  will 
be  given  directly.  Frictions  and  sinapisms  may  at  the  same  time 
be  used  with  advantage.  The  great  merits  of  this  plan  are,  its 
antispasmodic  nature,  and  the  administering  of  small  doses  at 
very  short  intervals.  This  is  eminently  demanded  in  cholera. 
Phthisis  may  be  a  complaint  of  years  ;  hooping-cough,  of  months; 
typhus,  of  weeks  ;  pneumonia,  of  days ;  but  cholera  must  be 
numbered  by  its  hours,  half  hours,  or  even  minutes. 

Having  reached,  then,  this  conclusion,  I  may  add,  that  a 
rationale  for  such  a  treatment  is  discernible.  I  only  follow  many 
good  authorities  in  the  opinion  that  cholera  is,  symptomatically 
and  pathologically,  a  poison-spasm,  or  tetanus  of  the  ganglionic 
system.  Taken  early,  that  condition  may  be  -prevented^  by  mild 
opiates  and  stimulants,  in  the  premonitory  stage.  Later,  while 
any  medicines  will  act,  these  will  do  the  most.  What  is  needed 
in  confirmation  of  this  explanation,  more  than  is  given  by  the 
action  of  quinine  in  preventing  an  anticipated  chill,  or,  of  the 
same,  in  full  quininization,  curing  the  paroxysmal  disease  (a  tox- 
semic  newrosis)  of  intermittent?  An  antagonistic  influence  against 
that  which  so  perturbs  innervation  throughout  the  body;  such 


1  Ice  was  used,  and  lauded,  in  cholera,  by  the  celebrated  Broussais,  in  1832. 


CHOLERA.  496 

is  the  whole  defiiiUion  that  we  can  give  of  tlic  remedial  power 
shown  in  either  case. 

Let  me  be  more  specific  in  reference  to  treatment.  Premonitory 
diarrliu'a  is  very  generally  admitted  to  be  present  in  a  majority 
of  cases  of  cholera.'  In  the  East  Indies,  many  writers,  of  dif- 
ferent dates  (Lawrie,  1K;}2,  Stewart  Clark,  18G4,  etc.),  assert  such 
a  state  to  be  an  exception  instead  of  the  rule.  But  in  India, 
they  have  a  premonitory  or  incii)ient  stage  of  anotlier  kind  ; 
characterized  by  great  languor  or  depression,  with  restlessness, 
and  sometimes  ringing  in  the  ears,  occurring  mostly  at  night. 
Stewart  Clark  states'  that,  in  this  stage,  a  mild  opiate  ("-with  a 
little  calomel  or  blue  pill"),  with  a  cup  of  warm  tea  or  a  small 
dose  of  a  dilfusible  stimulant,  as  a  fewgrainsof  carbonate  of  ammo- 
nium, or  a  little  weak  warm  brandy  and  water,  will  arrest  the 
attack  in  a  great  portion  of  cases  otherwise  likely  to  become 
serious. 

Such  symptoms,  as  well  as  diarrhoea,  should  be  noticed  during 
a  cholera  epidemic  ;  and  I  believe  the  same  treatment  will  meet 
either.  Rest,  warmth,  and  mild,  composing,  but  gently  stimu- 
lating draughts  ;  paregoi'ic,  aromatic  spirit  of  ammonia,  tincture 
of  ginger,  lavender,  etc.,  with  a  mustard-plaster  over  the  abdo- 
men, and  a  hot  mustard  foot-bath,  if  coldness  of  the  body  increase, 
or  vomiting  begin ;  such  are  safe,  and  I  believe  will  be  efficient 
remedies.  The  above  may  be  called  the  first  or  prodromic 
stage.-* 

The  next  has  been  well  called,  by  Prof.  A.  Clark,  the  rice-water 
stage.  For  that,  the  treatment  I  have  described  as  given  to  me 
by  Prof.  Horner  is  particularly  adapted.  Mj"-  recipe,  based  upon 
his,  is  as  follows  : — 

R. ^Chloroform,  et 
Tinct.  Opii  et 
Sp.  Camph.  et 

Sp.  Ammon.  Aromat.,  aa  f^jss ; 
Creasot.,  gtt.  iij  ; 
01.  Cinnamom.  gtt.  viij  ; 
Sp.  Vin.  Gall.,  f^ij.— M. 

Dissolve  a  teaspoonful  of  this  in  a  wineglassful  of  ice-water  ; 
and  give  of  that  tAvo  teaspoonfuls  every  five  mimites;  followed  each 
time  by  a  lump  of  ice.'  Iced  water,  or  rice-water  to  which  com- 
mon salt  and  bicarbonate  of  sodium  have  been  added,  may  be 
given,  a  little  at  a  time,  as  a  drink.  I  would  also  give  a  table- 
spoonful  of  brandy  every  hour  or  two. 

Friction  of  the  limbs  with  brandy  and  red  pepper  will  be,  along 
with  large  mustard-plasters  on  the  back  and  pit  of  the  stomach, 
useful  to  promote  reaction. 

1  Barraut  asserts  fixed  contraction  of  the  pupil  to  be  the  first  prodromic  sign ;  M. 
Worms  makes  the  same  statement  in  regard  to  albuminuria. 

•  Hygiene  of  the  Army  in  India,  p.  12. 

3  The  published  experience  of  Dr.  Hamlin,  in  Constantinople,  confirms  the  impor- 
tance of  the  above  early  treatment. 

■*  I  take  from  Dr.  Aitken's  Practice  the  following  recipe,  much  used  and  approved  in 
India  and  England:  ^.—01.  Ani.si.  01.  Cajuput.,  01.  .Tuniperi,  au  3ss;  iEther,  3ss  ;  Liq. 
Acid.  Halleri  (?'.  e.  one  part  concentrated  sulphuric  acid  to  three  parts  of  rectified  spirit), 
3ss ;  Tinct.  Ciunam.,  5ij. — M.  Dose,  ten  drops  every  %  of  an  hour,  in  a  tablespoonful 
of  water. 


496  ZYMOTIC    DISEASES. 

The  third  stage  is  that  of  absolute  collapse  ;  blue,  pulseless, 
shrunken,  voiceless.  Should  a  case  go  on,  in  spite  of  the  above- 
mentioned  treatment,  into  this  state,  what  else  can  be  done?  All 
now  seems  to  be  desperate  experimentation.^  Let  the  ice-bags 
be  tried,  and  judge  them  by  the  trial.  I  would  also  try  bella- 
donna internally,  as  an  antagonist  of  vascular  spasm.  Leclerc, 
of  Tours,  introduced  it  in  1854 ;  Barraut,  of  Mauritius,  used  it 
(i  grain  every  half  hour),  and  reported  success.  He  also  employed 
hypodermic  injections  of  sulpliate  of  atropia.  Drs.  Hodges,  of  St. 
Louis,  and  R.  Saunders,  report^  success  with  this  last  iDractice. 
It  should  be  further  tried  in  bad  cases.  So  might  be,  as  was  sug- 
gested by  me  in  1855,  warm  haths  of  infusion  of  strcmioniwni  leaves; 
on  the  same  indication.  Dr.  Brunton^  calls  attention  to  the 
similarity  between  tlie  symptoms  of  cholera  and  those  following 
poisoning  with  "poisonous  muslirooms"  (e.  f/.,  Amanita  mus- 
caria);  and  to  the  experiments  of  Schmiedeberg,  showing  atropia 
to  be  remedial  in  such  a  condition,  at  least  in  animals.  Drs.  A. 
R.  Hall,  Higginson,''  and  Blumenthal  report  the  recovery  of 
several  severe  cases  under  the  use  o\' hydrate  of  chloral  (one  part  in 
ten  of  water)  by  hypodermic  injection.  Dr.  W.  PeppeT^has  pro- 
posed the  injection  into  a  vein  of  a  solution  of  bromide  of  potas- 
sium; about  a  pint  of  water,  temperature  105°  F.,  containing  50 
to  75  grains  of  the  bromide,  being  introduced  at  once.  Also,  the 
injection  of  hotliquids  into  the  rectum ;  the  warm  bath  {hot  baths, 
in  some  cases,  at  least,  which  I  have  seen,  cause  distress  in  the 
collapse),  with  carbonate  of  ammonium  added,  as  usual  sometimes 
in  malignant  scarlet  fever  (West)  in  children  ;  or  the  warm  inus- 
tard  bath.  Hot  air^  bathing,  if  practicable,  would  be  worth  try- 
ing ;  and  so  would  chlorine  water,  and  the  inhalation  of  nitrous 
oxide.  Chloroform  inhalation  has  been  used  as  a  palliative  by 
some  British  practitioners.  Let  us  confess  honestly,  for  it  is 
wise  to  do  so,  our  art  is  here  very  weak ;  fifty  per  cent,  or  more  of 
collapsed  cases  die ;  shall  we  not  endeavor  to  discovem^-vf  resources  ? 
All  honor  to  those  who,  at  the  risk  of  their  own  lives,  contend 
yet,  with  so  forlorn  a  hope,  and  so  little  glory  to  be  won.  There 
is  room  for,  and  possibility  of  obtaining,  a  final  triumph. 

Two  words  remain  still  to  be  said,  with  short  comment :  house 
to  house  visitation,  and  houses  of  refuge.  These  are  measures  of 
great  consequence,  shown  to  be  of  value  during  cholera  epidemics. 
The  latter,  especially,  is  of  notable  importance  ;  that  is,  the  estab- 
lishment of  Houses  of  Refuge  in  salubrious  places,  into  which 
persons  from  tainted  districts  most  liable  to  the  disease  may  be 
received,  on  the  occurrence  there  of  the  first  cases. 

That  there  are  such  tainted  districts  has  been  amply  jjroven. 
Thus,  Dr.  Laycock  has  shown  that  in  York,  England,  the  first 
death  from  cholera  occurred  in  the  spot  where  plague  had  been 


1  Duchaussoy  and  Vernois  assert  the  non-absorption  of  medicines  given  by  the 
stomach  during  the  collapse ;  but  Magendie  proved  that  very  slow  absorption  does 
occur. 

2  Amer.  Practitioner,  July,  1873  ;  and  St.  Louis  Med.  Journal,  for  the  same  month. 

3  Med.  Times  and  Gazette.  Oct.  11,  1873. 

^  Indian  Medical  Gazette,  Nov.,  1873,  and  Jan.,  1874. 

6  Philadelphia  Jled.  Times,  July  12,  and  August  23,  1873. 

*Dr.  George  Johnson  states  that  he  has  seen  the  hot-air  bath  used  without  success. 


RHEUMATISM.  497 

traditionally  the  worst,  in  a  badly  drained  district.  In  Edinburgh, 
the  tirst  case  in  184S  occurred  in  the  same  house  as  did  the  first 
in  18;i2.  In  Holland,  at  the  town  of  Groningen,  in  1832  and  1848 
but  two  houses  in  the  lietter  part  of  the  town  were  attacked  ;  the 
same  houses  exactly  in  both  epidemics. 

Dr.  Alison  reports  tliatin  thetirst  three  months  of  the  epidemic 
at  Edinburgh,  in  18;}2,  353  persons  were  taken  in  at  Houses  of 
liefuge,  from  70  tainted  districts,  houses  and  rooms  in  which 
decided  cases  or  deaths  had  occurred.  Of  these,  only  15  took 
the  disease,  and  7  died  after  removal.  Of  the  346  thus  surviving 
brief  exposure,  it  is  very  probable  that  more  than  half  would 
have  died  had  they  remained  in  the  midst  of  the  infection.  At 
Glasgow,  in  1849,  401  persons  were  taken  into  Houses  of  Refuge 
from  tainted  districts  ;  only  V.)  of  these  took  the  disease,  and  but 
5  died.  At  Oxford.  England,  the  same  year,  of  70  persons  so  taken 
in,  none  died.  The  London  Board  of  Health,  in  its  "General 
Report,"  gives  the  fact  that  of  1691  of  whom  the  Board  had 
accounts  as  taken  into  Houses  of  Refuge,  but  33  were  attacked, 
with  only  10  deaths.  These  numbers  would  have  been  larger, 
but  for  the  very  common  unwillingness  of  poor  and  ignorant 
people  to  leave  their  homes,  chiefly  from  want  of  confidence  in 
the  greater  safety  of  so  doing.  Could  this  be  overcome,  I  have 
no  doubt  that  an  immense  saving  of  life  might  be  produced  by 
Houses  of  Refuge,  allowing  also  the  places  which  are  proved 
"  foci  of  infection  "  to  be  thoroughly  purified  at  once. 

House  to  house  visitation,  by  sanitary  inspectors  to  abate 
nuisances,  small  and  great,  and  by  medical  men  to  treat  premon- 
itory symptoms,  might  also  have  great  preventive  value.  The 
establishment  of  cholera  hospitals  may  be  made  necessary  when 
the  number  of  cases  is  great,  especially  as  the  greatest  propor- 
tion always  happens  among  the  poor,  who  are  ill  provided  for 
attendance  at  their  homes. 


DIATHESES. 

RHEUMATISM. 

Several  affections  are,  in  popular  language  (partly  sanctioned 
by  medical  usage),  included  under  this  term.  1.  Acute  articu- 
lar rheumatism,  or  rheumatic  fever.  2.  "Chronic  rheumatism," 
affecting  the  joints  and  sheaths  of  the  muscles.  3.  Syphilitic 
rheumatism,  of  the  long  and  flat  bones.  4.  "Rheumatoid 
arthritis."     5.  Myalgia.     6.   "  Gonorrhoeal  rheumatism. " 

Acute  Rheumatism. — Only  certain  persons  and  families  are 
liable  to  this  affection  upon  any  exposure.  It  is  characterized 
by  high  fever  with  severe  inflammation  of  several  of  the  larger 
and  smaller  joints ;  which  mostly,  one  after  another,  become 
swollen,  red,  hot,  tender,  and  painful.  The  shoulders,  wrists, 
knees,  and  ankles  are  most  frequently  so  affected.  Although 
with  a  full  and  rapid  pulse,  the  skin,  after  the  first  week  or  so 
of  the  disorder,  is  often  bathed  in  perspiration.  The  duration 
of  an  attack  under  various  modes  of  treatment  has  averaged 
nearly  three  weeks.  Sometimes  it  extends  over  months  ;  and 
42*  2G 


498  DIATHESES. 

the  sequelae,^  or  resulting  crippling  of  the  articulations,  may  remain 
for  a  lifetime. 

The  danger  in  rheumatic  fever  consists  chiefly  in  the  liability 
to  endocarditis  and  pericarditis.  A  singular  complication  of  it/ 
occasionally  met  with  at  a  late  stage,  is  chorea.  Rheumatism 
may  undergo  metastasis  from  the  joints  to  the  bronchial  tubes 
(rheumatic  bronchitis),  or,  much  more  rarely,  to  the  membranes 
of  the  brain.  The  latter,  cerebral  rheumatism^  is  decidedly  danger- 
ous. In  feeble  persons,  the  bowels  or  the  womb  may  occasion- 
ally be  involved. 

The  hlood  in  acute  rheumatism  is  found  to  contain  an  excess  of 
fibrin.  Lactic  acid  has,  upon  some  basis  of  observation  and 
experiment  (Richardson),  been  asserted  to  be  in  excess  in  the 
blood  as  the  characteristic  pathological  element  in  rheumatism. 

Apart  from  the  cardiac  affections  possible  in  its  course,  rheu- 
matic fever  is  not  often  dangerous  to  life  ;  but  it  is  very  painful 
and  debilitating. 

Treatment. — Many  methods  have  been  and  still  are  in  use. 
Opium  (Corrigan)  alone,  or  with  ipecac,  as  in  Dover's  powder  ; 
lemon-juice;  quinine;  colchicum;  alkalies;  and  salicylic  acid;  these 
are  the  most  important.  Recoveries  under  the  alkaline  treatment 
have  taken  place  many  times,  within  a  week,  where  the  symptoms 
indicated  a  probably  long  attack.  Of  417  cases.  Dr.  Fuller 
reports,  under  alkaline  treatment,  none  fatal,  and  only  nine 
suffering  with  cardiac  complications.  Dr.  Dickinson,^  in  St. 
George's  Hospital,  in  a  considerable  number  of  cases,  found  the 
proportion  of  those  in  which  the  heart  was  involved,  under  non- 
alkaline  treatment,  more  than  one  in  four ;  under  alkalies,  one 
in  forty-eight.  Carbonate  or  bicarbonate  of  potassium,  with  the 
Rochelle  salt  or  nitrate  of  potassium  (in  scruple  doses  of  the 
carbonate,  or  half-drachm  of  the  bicarbonate,  with  about  the 
same  of  either  of  the  other  salts),  thrice  daily,  will  answer  [P. 
37,  45,  46j .  Opiates,  especially  Dover's  powder,  at  night,  may 
do  great  good.  Local  application  of  laudanum  (detained  by  oiled 
silk^  to  the  painful  joints,  gives  much  relief. 

Lemon-juice  (O.  Rees)  has  seemed  to  me  a  useful  adjuvant 
(tablespoonful  doses  every  three  hours)  in  cardiac  inflamma- 
tions of  rheumatic  origin. 

Quinine  is  sometimes  very  beneficial  in  enfeebled  cases,  with 
free  perspiration.  10  or  15  grains  may  be  given  in  a  day.  Briquet 
and  others  in  Paris  have  given  60  grains  in  a  day. 

Colchicum  is  of  decided  service  in  the  presence  of  the  gouty 
diathesis ;  sometimes  useful  at  the  beginning  of  other  cases. 

Dr.  Da  Costa '^  reports  favorable  results,  especially  in  the  appa- 
rent prevention  of  cardiac  affections,  with  bromide  of  ammonium, 
in  15-  or  20-grain  doses. 

Veratrumviride  has  been  especially  praised  for  its  action,  in  small 
or  moderate  doses,  in  acute  rheumatism,  by  Henser,  in  Germany. 

1  First  remarked  by  See  of  Paris  and  Senliouse  in  England. 

2 Lancet,  Jan.  and  Feb.,  1869.  Drs.  Gull  and  Sutton  (Lancet,  Jan.  16  and  30,  1869) 
insist  that  cases  treated  merely  by  rest  in  bed  do  as  well  without  any  medicine  as  with 
it.    As  above  shown,  I  am  not  ready  to  accept  this  as  proven. 

'  Pennsylvania  Hospital  Reports,  1869. 


R  IT  E  IT  M  A  T  I S  M  .  499 

Remarkable  success  has  been  reported  in  the  treatinciiit  of 
rheumatisiu  by  "flying  blisters;"  i.  c,  tiie  successive  apijlication, 
to  dillercnt  afl'ected  parts,  of  small  blisters;  allowed  to  i)roduce 
moderate  vesication  only.  Drs.  Uavies,  Peacock,  and  other  Brit- 
ish physicians  laud  this  practice. 

Chevallereau  (La  France  Med.,  1880,  p.  724)  found  hypodermic 
injections  of  ergotin  to  give  considerable  relief. 

I'rnpi/lantin  I  have  tried  without  success.  Gaston,  Besnier,  and 
Dujardin-Beauinetz  report  very  favorably  of  it.'  I)r.  J.  Russell 
Reynolds'-  asserts  good  results  in  six  out  of  eight  cases  treated 
with  tincture  nf  chloride  of  iron.  Dr.  R.  Bartholow  also  approves 
of  this  practice. 

Dr.  Anstie^  remarks  upon  the  value  of  the  chloride  of  iron  as 
a  prophylactic  in  incipient  rheumatism.  Strieker  introduced  (1876) 
salicj/Hc  acid^  in  7-20  grain  doses,  with  good  effects ;  others  also 
give  it  praise.  (Glycerin  and  alcohol  promote  its  solubility.  See 
F.  202.)  Among  those  who  early  employed  it  were  Traube, 
Broadbent,  Maclagan,  See,  B^rard,  Beaumetz,  Jaccoud,  and 
Lepine.  Strieker  and  See  gave  from  a  drachm  and  a  half  to  two 
drachms  or  more,  daily.  Experience  shows  that  it  is  not  always 
safe  in  such  large  doses.  Sudden  death  has,  in  a  few  cases, 
appeared  to  be  thus  produced.  All  needful  effect  can  probably 
be  secured  by  giving  10  grains  every  hour  for  five  or  six  hours, 
and  afterwards  the  same  amount  thrice  daily.  Under  such 
treatment,  the  duration  of  the  severity  of  attacks  of  acute  artic- 
ular rheumatism  has  been  many  times  reduced  to  two,  three,  or 
four  days.  Whether  cardiac  complications  are  made  less  frequent 
or  less  dangei'ous  by  the  use  of  salicylic  acid,  can  hardly  yet  be 
considered  as  finally  settled.  I  fear  that,  so  far,  the  probabilities 
are  on  the  side  of  disappointment.  As  to  the  articular  symp- 
toms, however,  no  remedy,  not  even  alkalies,  can  show  so  much 
experimental  testimony  in  its  favor. 

If  salicylic  acid  produce  noises  in  the  ears,  or  deafness,  it  should  ' 
be  discontinued.  Copious  perspiration  is  also  a  sign  of  its  taking 
full  effect.  Excessive  doses  are  unsafe ;  a  few  fatal  results  have 
been  reported.  As  Dr.  A.  Flint  has  m-ged,  the  use  of  salicylic 
acid  need  not  supersede  that  of  alkalies — long  proved  to  be  so 
valuable  in  articular  rheumatism ;  the  two  modes  of  treatment 
do  not  conflict  with  each  other,  but  may  be  combined. 

S(dici/Iate  of  sodium  has  all  the  effects  of  the  uncombined  acid, 
while  it  is  less  disagreeable  and  more  soluble.  Its  dose  must  be 
about  two-thirds  larger  than  that  of  salicylic  acid. 

Ilarley  and  Bartholow  speak  well  of  the  use,  for  severe  rheu- 
matic pains,  of  hypodermic  injections  of  atropia.  I  have  always 
found  relief  to  follow  the  local  application  of  laudanum :  laying 
upon  the  aflected  joint  lint  or  cotton  saturated  with  laudanum 
and  covered  with  oiled  silk. 

Dr.  D.  MacEwen*  has  found  henzoate  of  sodium  efficient,  in  severe 
cases,  in  relieving  pain  and  reducing  fever  in  acute  rheumatism. 

1  London  Med.  Record,  Jan.  29,  1873. 

2  Brit.  Med.  Journal,  Aug.  28,  18G9. 

3  The  Practitioner,  September,  1871. 

*  Brit.  Med.  Journal,  vol.  i.,  1881,  p.  336. 


500  DIATHESES. 

He  has  given  it  in  doses  of  from  15  to  20  grains  every  two  or  three 
hours,  diminishing  the  amomit  as  the  symptoms  of  the  attack 
decline. 

In  cerebral  rheumatism,  the  use  of  cold  haths  (H.  C.  Wood, 
Woillez')  has  been  reported  to  produce  more  beneficial  results 
than,  a  priori,  might  have  been  anticipated. 

Chronic  Rheumatism. — Anyone  may  have  this  affection, which 
is,  however,  most  common  among  those  advancing  in  age.  It  is 
a  sort  of  slow  inflammation  of  the  fibrous  tissues  investing  the 
joints  and  muscles,  following  exposure  to  cold  and  wet.  The 
aching  pains  are  apt  to  be  worst  at  night. 

Gold  may  produce  pain,  without  any  inflammation.  Five  min- 
utes' exposure  to  a  draught  of  damp  air  will  often  thus  affect 
different  parts  of  the  body;  relief  being  at  once  obtained  on  the 
application  of  warmth.  This  fact,  of  cold  directly  producing  pain^ 
especially  in  the  muscles,  ought  not  to  be  overlooked.  It  supports 
Inman's  and  Eadclift'e's  idea,  that  pain  is  always  a  sign  of  the 
local  or  general  diminution  of  vitality.  Dr.  E.  C.  Wendt'^  asserts 
evidence  showing  that  some  cases,  designated  as  rheumatism,  are 
to  be  explained  as  the  secondary  effects  of  trichinosis. 

The  treatment  of  chronic  rheumatism  has  been  largely  experi- 
mental. The  medicines  most  given  are  iodide  of  potassium, 
guaiacum  [F.  167],  oil  of  turpentine,  and  cod-liver  oil.  Alkalies 
and  colchicum  do  not  signally  affect  it.  Oil  of  cajuput  is  some- 
times very  serviceable.  Opium  is  seldom  required  unless  locally. 
Local  treatment  generally  does  more  for  it  than  medicine.  For 
this,  various  liniments  are  useful.  I  have  found  none  better  than 
one  containing  oil  of  turpentine,  oil  of  sassafras,  ammonia,  and 
laudanum,  diluted  with  soap  liniment  •,  or,  where  pain  is  consid- 
erable, chloroform  or  aconite  liniment.  Blisters  may  be  applied 
in  bad  cases.  Guarana  (Rawson),  internally,  has  lately  been 
advised.  Dr.  Franz  Heller'^  asserts  the  positively  curative  influ- 
ence of  liquor  ammonice  (taken  internally)  in  muscular  rheu- 
matism. 

Dry  cupping  to  the  back.,  leaving  a  number  of  cups  on  for  twenty 
or  thirty  minutes  at  a  time,  makes  a  more  pervading  favorable 
impression,  sometimes,  than  might  have  been  expected.  For 
rigidity  of  the  joints,  and  even  for  pain  in  them  or  in  the  muscles, 
pouring  hot  water  continuously  over  the  parts  does  great  service. 
The  hot  bath,  or  vapor  hath,  or,  as  some  prefer,  the  hot  dry  air 
bath  (130°  to  200°)  will  be  powerful  for  relief  in  many  cases. 
Galvanism  also  will  aid  in  hastening  the  restoration  of  use  to  the 
stiffened  parts.  Wrapping  rheumatic  joints  in  cotton,  or  covering 
them  with  India-rubber  cloth,  is  often  very  serviceable.  Those 
subject  to  rheumatism  should  wear  flannel,  different  in  thickness 
according  to  the  season,  through  the  whole  year. 

Syphilitic  Rheumatism. — As  stated  already,  this  affects  the 
long  and  flat  bones  chiefly,  and  mostly  between  the  joints,  not  at 
them.  Generally,  there  is  nodosity  upon  the  bones  affected,  or 
some  degree  of  periosteal  inflammation,  at  least, 

1  L'Union  Medicale,  Oct.  14, 1880. 

2  Am.  Journal  of  Med.  Sciences,  April,  1878. 
?  Wiener  Med.  Presse,  December,  1875. 


RHEUMATISM.  501 

Hie  remedy  for  sy{)liilitic  rlicuiuiitisni'  is  iodide  of  potassium. 
I  have  never  known  it  to  fail  to  i-elieve  the  pains  in  a  very  few 
days.  They  may  return  in  the  eourse  of  months  or  weeks,  when 
the  same  treatment  should  be  renewed.  (Ten  to  twenty  grains 
of  the  iodide,  thrice  daily,  will  sufliee.)     [F.  108.] 

Rheumatoid  Arthritis.— This  designation  is  applied  by  authors 
(first  by  Garrod,  1S."),S)  to  a  form  of  suljacute  or  chronic  inflanniia- 
tion  of  one  or  more  larire  joints,  of  greater  severity  than  ordinary 
chronic  rheumatism.  Eifusion  into  the  joint,  with  deformity  and 
permanent,  or  at  least  long-continued,  lameness,  may  occur.  I 
doubt  the  intlumce  of  the  gouty  diathesis  in  this  aflection;  while 
constitutional  debility  no  doubt  often  promotes  it.  Sometimes  it 
extends  to  nearly  all  the  joints  in  the  body,  producing  distortion 
and  deformity,  and  making  the  patient,  especially  if  elderly, 
entirely  helpless.  Even  the"  jaws  and  neck  may  be  affected;  but 
much  rigidity  in  them,  from  this  cause,  is  rare.  The  cartilages 
of  the  joints  are  absorbed,  and  nodosities  or  condyloid  "lips" 
occur  upon  the  bones.  A  grating  sound  is  sometimes  heard  when 
they  are  moved. 

Kheumatoid  arthritis  differs  from  gout  in  its  attacks  being 
much  less  acute  and  violent,  and  in  the  continuance  and  usually 
steady  progress  in  the  swelling  and  deposit  in  the  joints.  More- 
over, "it  is  not  known  to  be  hereditary,  or  to  have  any  direct  rela- 
tion to  diet  or  hal)its  of  life.  It  is  more  common  in  women  than 
in  men,  and  may  occur  in  patients  of  any  age. 

In  treatment,  iron,  cod-liver  oil,  iodide  of  potassium,  and 
arsenic  are  the  preferred  medicines.  Massage^  with  very  tender 
handling  of  the  joints,  may  do  good.  Locally,  stiiall  blisters  some- 
times arrest  the  enlargement,  and  even  dissipate  the  effusion. 
Ointment  of  iodoform  (Moleschott),  mercurial  ointment,  and 
cerate  of  carbonate  of  lead,  may  all  be  tried  by  nightly  appli- 
cation, persevered  in  for  a  week  or  more  at  a  time.  If  pain  be 
considerable,  belladonna  liniment  may  be  recommended.  Salt 
baths,  warm  or  hot  (not  continued  so  long  as  to  relax  overmuch), 
are  likely  to  (Jo  good,  if  the  patient  can  be  moved  without  too 
much  inconvenience  on  account  of  the  rigidity  of  the  articula- 
tions. Electricity,  also,  may  promote  improvement,  and,  in 
young  persons,  recovery. 

Can  rheumatism  and  gout  ever  be  actually  combined  in  the 
same  patient,  in  a  hybrid  attack?  I  am  sure  that  they  can,  at 
least,  be  so  far  blended  together  that  inflammatory  rheumatism, 
in  a  patient  of  gouty  constitution,  is  more  affected  by  the  state 
of  the  digestive  organs,  and  is  more  beneficially  acted  upon  by 
colchicum,  than  in  others.  I  will  consider  the  diagnostic  com- 
parison between  rheumatism  and  gout  hereafter. 

Myalgia. — Dr.  Inman,  of  Liverpool,  first  gave  this  name  to 
muscular  pain  without  inflammation  or  other  defined  disease. 
It  is  more  often  met  with  in  the  hack  and  chest  than  elsewhere. 
Debility  and  fatigue  are  its  principal  causes ;  although,  as  I 
have  said,  muscular  pain  may  follow  from  the  direct  impression 
of  cold. 


1  First  thus  used  by  Dr.  R.  Williams,  of  St.  Thomas's  Hospital,  London. 


502  DIATHESES. 

Rest,  warmth,  and  tonics  meet  the  general  indications  for  the 
treatment  of  myalgia.  Anodyne  applications,  as  aconite  lini- 
ment or  tincture,  or  veratria  ointment,  will  be  required  only  in 
a  few  cases.     The  hot  bath  or  douche  may  often  give  relief. 

Gonorrhoeal  Rheumatism. — After  Swediaur  ^1781)  and  Sir 
Astley  Cooper,  several  English  and  French  writers  have  de- 
scribed a  peculiar  intlamnjation  of  one  or  more  joints,  mostly  of 
one  only,  occasionally  commencing  in  the  course  of  gonorrhoea, 
or  even  "of  urethral  inflammation  from  forced  catheterism.  FoUet 
asserts  that  it  occurs  in  1  in  35  cases  of  gonorrhoea  in  men ;  miich 
less  often  in  women.  Gonorrhoeal  sciatica  is  described  by  Four- 
nier.^  The  local  affection  may  be  severe,  with  suppuration  in  a 
few  cases,  and. anchylosis  of  the  joint  in  many.  It  appears  to 
be  an  ichorhcemic  affection,  i.e.,  the  result  of  absorption  into  the 
blood  of  morbid  matter  effused  into  or  formed  upon  the  mem- 
brane of  the  urethra. 

Treatment. — Chambers  and  Brodhurst,  on  the  ground  of  ex- 
perience, recommend  active  treatment  for  this  affection,  by  mod- 
erate bleeding,  general  in  the  robust,  and  local  in  others,  followed 
by  blisters,  the  hot-air  bath,  chloride  of  ammonium,  and  opiates 
at  night. 

GOUT. 

Synonyms. — Podagra ;  Arthritis. 

Gout  is  a  diathesis,  or  constitutional  disorder,  more  or  less  per- 
sistent, with  local  afi'ections,  mostly  inflammatory,  occurring  in 
paroxysmal  attacks. 

Symptoms. — Premonition  of  a  gouty  spell  is  often  witnessed 
for  some  days,  with  S3'mptoms  of  indigestion,  flatulence,  acidity, 
constipation,  palpitation  of  the  heart.  Then  (or  without  such 
warning)  a  joint  becomes  very  painful,  swollen,  red,  and  tender. 
In  a  majorit}^  of  cases  the  great  toe  is  aftected.  Other  toes,  the 
fingers,  ankle,  wrist,  or  knee,  ma}^  be  attacked ;  the  large  joints 
least  often.  Towards  the  end  of  the  spell,  tophaceous  or  chalk- 
like deposits  (chieflj-  of  urate  of  sodium  and  calcium,  altering 
with  time  in  part  to  carbonates)  are  thrown  out  about  the  joint, 
in  some  but  not  in  all  cases. 

The  suffering  with  the  gouty  inflammation  is  often  very  intense  ; 
but  its  duration  is  not  commonly  more  than  a  few  daj^s  at  a  time. 
Aptness  to  return,  at  intervals  shortening  with  each  attack,  is  an 
unpleasant  feature.  When  the  period  of  release  is  so  short  as  to 
be  almost  absent,  it  is  called  chronic  gout. 

Retrocedent  or  misplaced  gout  is  that  in  which,  instead  of  the 
small  joints,  some  internal  organ  is  affected,  as  the  stomach  or 
heart.  Such  attacks  are  violent  and  threatening  to  life,  but  gen- 
erallj'  brief  Exposing  an  inflamed  gouty  foot  to  cold  may  thus 
"drive  in"  the  disease,  or  produce  a  metastasis.  Bronchitis, 
according  to  some  authors  {e.g.,  J.  M.  Fothergill),  is  the  most 
common  manifestation  of  gout  next  to  arthritis. 

If  the  stomach  be  so  involved,  nausea,  vomiting,  and  spasm  or 
cramp  of  the  stomach  are  experienced,  which,  unless  relieved  in 

1  Grazette  Hebdomadaire,  No.  48, 1868. 


GOUT.  503 

a  short  time,  prostrate  the  pf^tient  very  much.  When  the  heart 
is  the  ortran  seized,  its  action  i.s  interfered  with  so  as  to  cause 
distress  in  breathing,  pallor,  faintness,  and  debility. 

The  ttrine,  during;  the  attack  of  irout,  is  scanty,  with  its  usual 
amount  of  urea,  but  a  deficiency  (tf  uric  acid  until  near  the  close 
of  the  spidl,  when  tlie  latter  is  increased.  The  persynraiion  not 
unfrequently  contains  an  excess  of  uric  acid  and  the  urates,  par- 
ticularly urate  of  sodium. 

Hereditary  cjout  is  sometimes  genuine  podagra,  or  foot-gout, 
but  more  often  is  of  the  icanderirvj  kind.  Xeuralgia,  indigestion, 
palpitation,  and  urticaria  or  eczema  upon  the  skin,  are  its  most 
common  manifestations.  In  such  a  system  rheumatism  and 
other  affections  are  to  a  considerable  degree  modified  by  "the 
gouty  tendency."  I  believe  this  tendency  to  be  too  much  over- 
looked in  practice. 

Morbid  Anatomy.— Except  the  deposits  of  urates  about  the 
joints,  and  the  jiroved  excess  of  uric  acid  in  the  blood,  the  only 
peculiar  alteration  belonging  to  the  anatomy  of  gout  is  the 
shrinking  and  granular  degeneration  (with  some  deposit  of  urate 
of  sodium)  of  "the  kidney;  the  "gouty,  contracted  kidney"  of 
Todd.     This  deposit  is  pathognomonic  of  gout. 

Pathology.— Garrod  has  established  the  doctrine^  of  the  char- 
acteristic of  gout  being  excess  of  uric  acid  in  the  blood.  The  origin 
of  this  excess  is  still  doubtful.  The  view  of  Mialhe  is  plausible, 
that,  urea  being  more  highly  oxidized  than  uric  acid,  deficiency 
of  oxygenation  of  the  blood  may  increase  the  amount  of  uric  acid 
in  it,  unchanged.-  Also,  imperfect  action  of  the  kidneys  may, 
by  their  not  depurating  the  blood  fully,  induce  the  same  accumu- 
lation. CuUen,  Laycock,  Melden,  Liveing,  and  Duckworth'  have 
held  gout  to  be  essentially  a  yieiirosis.  Duckworth  proposes  the 
term  "neuro-humoral"  for  the  class  of  disorders  to  which  it 
belongs.  The  fact  seems  to  be  that  it  is  as  truly  constitutional  as 
any  malady  can  be,  the  symptoms  affecting  the  nervous  system 
being  no  more  prominent  than  those  involving  the  articulations 
and  other  parts  of  the  body. 

Causation. — High  living,  with  indolent  habits,  generates  gout. 
Even  excess  of  animal  food,  with  scanty  exercise,  I  have  known 
to  produce  it.  But  strong  wines  and  malt  liquors  much  increase 
the  tendenc}'.  Weak  wines  do  not  seem  to  have  the  same  effect. 
In  the  Rhine  region  gout  is  rare.  Xor  do  spirits  produce  it 
readily;  their  effects,  when  abused,  are  different,  though  worse 
in  the  end.  Hereditary  transmission  of  the  gouty  constitution 
is  very  common. 

Diagnosis. — Between  gout  and  rheumatism  there  is  great  re- 
semblance ;  and,  as  I  have  observed,  they  may  be  blended 
together.  AVhen  clearly  exemplified,  the  following  differences 
exist : 

In  gout  the  small  joints  are  chiefly  affected  ;  in  rheumatism  the 
larger  joints.  Repetition  of  attacks  is  much  more  frequent  in 
gout ;  their  duration  is  greater  in  rheumatism.     In  gout  the  heart 

1  Suggested  by  Murray  Forbes,  and  afterwards  by  Prout. 
-  Headland  and  others  advocate  a  quite  different  view. 
»  Brain,  April,  18S0. 


504  DIATHESES. 

is  seldom  attacked,  and  spasmodically;  in  rheumatism  the  heart  is 
often  subject  to  inflanmiation.  In  gout  the  stomach  is  sometimes 
spasmodically  affected  with  violent  symptoms;  in  rheumatism 
almost  never,  although  the  bowels  may  be.  In  rheumatism,  the 
fever  is  much  more  marked  and  continued  in  proportion  to  the 
local  symptoms,  notwithstanding  copious  perspirations.  In 
gout,  and  not  in  rheumatism,  uric  acid  (or  urate  of  sodium)  is  in 
excess  in  the  blood.  In  pure  gout  colchicum  generally  does  good  ;- 
in  pure  rheumatism  hardly  ever. 

Treatment. — During  the  attack,  colchicum  and  the  alkalies  are 
the  best  remedies.  Wine  of  the  root  (some  prefer  that  of  the 
seeds)  of  colchicum  may  be  given  in  ten-  to  twenty-drop  doses 
several  times  daily.  The  stomach  and'  bowels  are  sometimes 
irritated  b}'  large  doses ;  but  for  a  few  days  most  patients  will 
bear  fifteen  drops  thrice  daily.  .  It  should  be  stopped  when  relief 
has  been  obtained.  Carbonate  of  potassium,  ten  to  thirty  grains 
at  once,  with  half-drachra  doses  of  Rochelle  salt,  will  be  important 
in  addition  [F.  37,  45,  46].  Garrod  and  Petit  speak  highly  of  the 
anti-arthritic  powers  of  lithia ;  experiments  with  the  carbonate 
having  shown  in  it  some  capacity  to  dissolve  gouty  deposits. 
The  urate  of  lithium  is  the  most  soluble  of  the  salts  of  uric  acid. 
Sjpectroscopic  examination  shows  that  a  minute  amount  of  lithia 
exists  ordinarily  in  human  blood.  The  citrate  of  lithium  is  pre- 
ferred by  some  practitioners.^  Opiates  or  other  anodynes  may  be 
craved  by  the  patient  during  the  extremity  of  his  pain. 

Shall  any  local  application  be  made  ?  Not  cold  to  reduce  the 
inflammation.  More  than  one  death  has  occurred  from  this,  by 
repulsion  of  the  disorder  to  the  heart,  stomach,  or  brain.  Leech- 
ing is  considered  to  increase  the  tendency  to  the  deposit  of  urates 
in  the  joints  affected.  Laudanum  may,  I  believe,  be  safely  applied 
to  the  part,  as  in  rheumatism,  by  wetting  a  piece  of  linen  or 
muslin  with  it,  laying  it  on  the  painful  joint,  and  covering  it  with 
oiled  silk.  Alkaline  washes  (not  too  cold)  are  sometimes  used. 
Oil  of  horse-chestnut  is  recommended  by  some. 

Gouty  attacks  affecting  the  stomach  or  heart  spasmodically  are 
usually  sudden,  violent,  and  prostrating ;  requiring  prompt  stim- 
ulation, as  by  brandy,  laudanum,  Hoffmann's  anodyne,  chloro- 
form, or  Warner's  cordial  (tinct.  rhei  et  sennse).  Small  or  mod- 
erate doses  of  one  or  another  of  these  should  be  given  at  short 
intervals.  Mustard  plasters  to  the  epigastrium,  or  chest,  and 
back  will  be  important ;  and  the  feet  may  be  placed  in  hot  mus- 
tard-water for  revulsion. 

Breathing  oxygen  has  been  proposed  as  a  remedy  for  the  gouty 
state  of  the  blood.  Its  utility  has  not  yet  been  decided  upon  by 
sufficient  trial. 

The  prevention  of  attacks,  by  the  removal  of  the  diathesis  and 
predisposition,  is  often  very  difficult,  even  in  the  absence  of  hered- 
itary taint.  Regulation  of  the  diet  is  of  primary  importance. 
But  it  should  not  be  too  low,  especially  when  the  patient's  habits 
have  been  those  of  a  free  liver.  Nourishment  must  be  full,  while 
the   digestive  power  is   economized,   and   positive   stimulation 

1  Of  the  effervescing  citrate  of  lithium,  the  dose  is  from  three  to  five  grains. 


SCURVY.  505 

avoided.  Exercise,  in  proportion  to  strength,  should  be  recom- 
mended. In  some  weak  or  old  eases  tonics  may  be  called  for; 
vegetable  bitters  particularly.  The  state  of  the  skin,  as  well  as 
of  the  hotvch,  is  important. 

Change  of  air,  travelling,  and  mineral  waters  are  generally 
useful  during  the  intervals  between  the  paroxysms.  Alkaline 
springs  and  l)aths  (such  as  those  of  Vichy,  in  France,  Ems,  in 
Germany,  or  Gettysburg,  in  Pennsylvania)  have  an  especial 
reputation  as  prophylactic  against  gout.  ^ 

SCURVY. 

Synonym. — Scorbutus.  This  affection  was  once  very  destruc- 
tive to  voyagers  at  sea  and  explorers  of  barren  regions,  as  well 
as,  sometimes,  to  large  armies.  Captain  Cook  has  the  credit  of 
proving  the  preventive  value  of  vegetable  food.  Dr.  Lind,  his 
contemi)orary,  published  a  work  on  scurvy  in  1757,  advocating 
the  antiscorbutic  use  of  oranges  and  lemons.  Still,  in  their 
Arctic  expeditions,  Drs.  Kane  and  Hayes  were  much  incommoded 
by  this  disease.  In  the  Crimean  war,  and  during  the  late  civil 
war  in  this  country,  although  uncomplicated  scurvy  was  not 
very  frequent,  the  scorbutic  diathesis  modified  other  diseases,  and 
increased  mortality  to  a  serious  extent. 

Symptoms. — Languor,  debility,  and  lowness  of  spirits  first 
occur.  Then  swelling,  sponginess,  and  bleeding  of  the  gums  are 
observed  ;  the  teeth  loosen,  and  the  breath  is  ofi'ensive.  Palpita- 
tion of  the  heart  and  dyspmea  may  be  present.  An  eruption 
resembling  acne,  and  afterwards  petechial  spots  (from  subcu- 
taneous extravasation  of  blood),  appear  on  the  limbs ;  some- 
times the  legs  swell  from  fibrinous  deposits,  especially  at  the 
ham.  Diarrhoea  and  dysentery  often  come  on.  Death  may 
take  place  by  gradual  exhaustion,  or  by  sudden  syncope. 

Diagnosis.— Pur2mr a  hemorrhagica  is  undoubtedly  not  identical 
with  scurvy,  although  "  purpuric  "  extravasations  are  common  to 
both.  Purpura  does  not  depend,  as  scurvy  does  chiefly,  upon  a 
fault  of  diet ;  nor  are  the  gums  affected  in  purpura. 

Causation  and  Pathology.— That  the  essential  cause  {sine  qud 
non)  of  scurvy  is  deprivation  of  fresh  food,  and,  in  almost  all 
cases,  of  fresh  vegetable  food,  is  proved.  Fresh  meat  will  retard 
it,  in  the  absence  of  vegetables ;  but  neither  this  nor  oranges  and 
lemons  will  altogether  prevent  it,  through  long  periods.  Addi- 
tional promotive  causes  are  severe  cold,  fatigue,  and  exposure, 
and  mental  anxiety  or  home-sickness. 

Further  than  this,  the  pathology  of  scurvy  has  not  been  deter- 
mined. The  hypothesis  that  it  depends  upon  deficient  alkalinity 
of  the  l:»lood  is  disproved  by  the  failure,  in  many  hands,  of 
potassa  and  its  compounds  to  hasten  the  cure,  or  insure 
prevention. 

Treatment, — Medicine  is  here  almost  valueless.  Fresh  vege- 
tables alone  will  restore  what  is  wanting,  though  chemistry 
has  not  detected  the  nature  of  the  need.  Potatoes  tomatoes, 
oranges,  and  lemonade  are  the  most  generally  available  articles. 
If  any  medicine  be  useful  as  an  adjuvant,  it  is  the  tincture  of  the 
43 


506  DIATHESES. 

chloride  of  iron,  in  moderate  doses.  Sometimes  citric  acid  does 
good. 

For  the  gums,  a  wash  of  solution  of  tannic  acid  or  tincture  of 
myrrh  in  diluted  glycerin  will  be  useful ;  or  alum,  brandy,  and 
water.  Salt  and  whisky  rubbing  to  the  skin  will  aid  in  dissipating 
the  petechise. 

Prophylaxis. — Medical  men  in  charge  of  expeditions  to  a  dis- 
tance from  ordinary  supplies,  should  always  insist  on  measures 
being  taken  to  furnish  enough  fresh  vegetables,  or,  next  best, 
desiccated  potatoes.  After  the  latter,  onions,  tomatoes,  turnips, 
salad,  etc.,  and  oranges  and  lemons  rank.  Wine  is  also  decidedly 
though  not  infallibly  anti-scorhutic.  The  leaves  of  the  pokeberry 
plant  {Phytolacca)  and  of  the  cactus  opuntia^  are  so.  Raw  meat  is 
better,  in  the  Arctic  regions,  for  the  same  end,  than  that  which 
is  cooked.  During  the  long  voyage  of  Professor  !N'ordenskj6ld 
around  the  north  coast  of  Asia,  not  a  single  case  of  scurvy 
occurred.  This  was  due  to  the  use  of  a  small  red  berry  that 
springs  out  of  the  ice  and  snow  in  the  short  summer.  It  is  dried, 
mixed  with  reindeer's  milk,  and  carried  in  a  frozen  state.  The 
experience  of  the  army  of  the  Potomac  during  the  late  war,  in 
the  McClellan  campaign,  shows  that  neglect  of  the  means  of 
preventing  this  disease  will  sometimes  cost  far  more  than  those 
means  themselves,  whatever  difficulties  they  may  seem  to  present. 

SCORBUTIC  DYSENTERY. 

This  term  appears  prominently  in  the  sanitary  and  medical 
reports  of  the  armies  in  the  Crimea.  In  the  Peninsular  Campaign 
in  our  late  war  (just  alluded  to  above),  the  Chickahominy  region 
was  the  seat  of  a  great  amount  of  disease,  partly  febrile  (typho- 
malarial  fever)  and  partly  scorbutic.  While  on  duty  in  the  sum- 
mer of  1862  in  two  U.  S.  General  Hospitals  in  Philadelphia,  I  met 
with  many  such  cases.  A  record  was  kept  of  thirteen  deaths  in 
the  Pourth  Street  Hospital,  from  what  I  then  designated  as 
"scorbutic  marasmus." 

These  men  were  brought  from  the  Chickahominy  very  much 
emaciated,  pale,  feeble,  without  appetite,  almost  without  power 
of  digestion,  and  with  moderate  diarrhoea.  Yomiting  occurred 
in  some.  Blue  or  nearly  black  purpuric  or  petechial  blotches 
appeared  on  their  arms  and  legs  ;  in  ih.e  fatal  cases,  over  the  breast 
and  abdomen  also.  But  one"  of  our  men  recovered  in  whom  the 
extravasations  occurred  on  the  breast ;  a  considerable  number  in 
whom  only  the  limbs  were  so  affected. 

The  diarrhoea  was  in  none  of  them  so  great  as  of  itself  to 
threaten  life.  Several  improved  under  treatment  (with  vege- 
table food,  fruits,  lemonade,  etc.)  for  a  while,  and  then  relapsed 
into  a  condition  not  unlike  in  aspect  to  the  collapse  of  cholera ; 
in  which  they  died.  Two,  after  seemingly  great  improvement 
for  a  week  or  more,  died  suddenly.  It  seemed  that,  in  them,  the 
blood  or  blood-making  power  was  hopelessly  ruined. 

Autopsy,  in  several  of  these,  and  in  some  patients  in  another 
ward  of  the  same  hospital,  under  the  care  of  Prof.  S.  D.  Gross, 
exhibited  coincident  lesions  not  often  described  tos-ether.    These 


SYPHILIS.  507 

were,  extensive  follicular  colitis,  and  double  pneumonia.  The 
latter  invariably  adbctcd  the  posterior  portions,  only,  of  the  lungs. 
Suppuration  had  occurred  in  the  lungs  in  two  of  our  cases  ;  hepa- 
tization in  three  or  four  more. 

The  condition  of  the  bowels  in  those  instances  was  thus  recorded 
in  my  notes  : — 

The  large  intestine,  especially  the  rectum,  was  extensively 
inflamed  ;  with  large,  rugose  tumefaction,  the  ridges  covered 
thickly  by  an  ash-colored  granular  and  diphtheritic  deposit  ;  the 
whole  surface  reddened  underneath  this,  and  the  blood-vessels 
generally  enlarged.  No  pus  was  found  ;  and  only  slight,  rare, 
and  superficial  spots  of  ulceration.  The  ileum  also  was  affected 
with  marked  hyperemia  and  swelling  of  the  mucous  membrane 
without  ulceration. 

I  give  these  facts  and  appearances  as  matters  of  medical  and 
pathological  history.  The  occasion  of  their  occurrence,  we  may 
well  trust,  will  never  exist  again  in  this  country. 

SYPHILIS. 

Few  old  subjects  have  been  so  completely  reopened  latterly  as 
that  of  syphilis.  Thirty  years  ago,  not  many  denied  the  unity 
of  the  syphilitic  poison  (distinct  from  that  of  gonorrhoea),  while 
all  admitted  the  multiplicity  of  its  manifestations.  Soft  chancre, 
indurated  chancre,  and  phagedi3enic  chancre  were  all  recognized, 
as  well  as  the  specific  bubo,  and  secondary  and  tertiary  syphilis. 
But  now,  prominent  authorities  {dualists)  urge  that  at  least  two 
poisons  exist,  productive  of  venereal  diseases,  not  mutually  inocu- 
lable  or  convertible.  This  I  am  not  satisfied  to  pronounce  proven. 
The  topic  is  altogether  rather  surgical  than  medical ;  but  as  the 
physician  must  often  deal  with  it,  I  propose  to  state  (perhaps, 
for  brevity's  sake,  rather  dogmatically)  what  I  conceive  to  be  the 
most  important  practical  points. 

The  "  Hun terian"  chancre  is  a  sore  on  the  male  or  female 
genitals,  slightly  cup-shaped,  vipon  an  indurated  base.  From  ten 
days  to  a  month  or  more  may  elapse  after  infection  before  the 
chancre  is  perceived.  Then  it  begins  as  a  red  pimple,  often  un- 
noticed until  it  ulcerates.  Its  discharge  is  moderate  in  amount, 
and  scarcely  purulent  except  undor  irritation  from  without. 

This  is  said  not  to  be  "auto-inoculable,"  i.  e.,  matter  from  it 
will  not,  if  introduced  anywhere  on  the  patient's  own  body,  pro- 
duce a  like  sore.  The  lymphatic  glands  may  become  aifected, 
with  enlargement  and  hardening,  not  suppurating  unless  dis- 
turbed and  inflamed.  The  constitutional  disease,  called  in  its 
manifestations  secondary  and  tertiary  syphilis,  results  from  infec- 
tion by  this  sort  of  chancre. 

The  "simple,  soft"  cha,ncre  or  chancroid  is  described  as  having 
no  period  of  incubation,  and  not  commencing  as  a  pimple  or 
tubercle,  but  as  an  abrasion,  which  discharges  pus.  If  a  bubo 
follow  it,  it  is  of  the  suppurating  kind.  The  system  is  said,  by 
recent  authorities,  not  to  be  involved  by  this. 

Pkagedcenic  chancre  is  characterized  by  unhealthy  purulent  dis- 
charge and  a  destructive  tendency  to  erosion.  Ulceration  of  the 
groin  may  follow  its  buboes.     Sloughing  chancre  may  be  regarded 


508 


DIATHESES, 


as  the  extremest  degree  of  this,  observed  under  conditions  of 
depressed  vitality. 

Now  in  the  above  discrimination  between  "  infecting  "  and 
"n  on -infecting  "  chancre,  tlie  former  being  considered  to  be  only 
that  with  indurated  base  and  non-suppurating  buboes,  I  follow 
late  authors,^  not  my  own  observation.  A  not  inconsiderable 
experience  in  the  treatment  of  syphilis,  in  hospital  and  private 
practice,  impresses  me  with  a  different  opinion  ;  viz.,  that  either 
the  hard-based  or  the  simple  soft  chancre  may  have  a  suppurating 
bubo  and  a  decided  constitutional  affection.  I  must  assert  that  I 
have  seen  those  results,  repeatedly,  follow  both.  Bradley's^  experi- 
ments upon  monkeys  and  other  animals  confirm  this  statement. 
Many  confirmed  "dualists  "  admit  that  it  is  sometimes  impossible 
to  distinguish  the  infecting  from  the  non-infecting  sore.  Some 
(as  JSTeumann,  of  Vienna),  are  "  unitist "  in  theory,  but  admit  the 
importance  of  the  diverse  manifestations  of  the  disease.  Bum- 
stead  (the  highest  American  authority)  supposes  it  possible  that 
"  chancroid  "  may  be  a  derivative  of  chancre.^  Bryant*  uses  tlie 
following  language  :  "Unfortunately,  in  a  clinical  point  of  view, 
this  great  distinction  between  the  two  forms  of  chancre  is  not 
always  to  be  made  out ;  and  consequently  an  intermediate  class 
of  cases  has  to  be  recognized,  approaching  in  its  clinical  features 
more  the  soft  sore,  which  is  capable  of  giving  syphilis." 

Sturgis  gives  the  following  table  of  comparative  diagnosis : — 

CHANCROID. 


INITIAL   LESION. 

Decided  period  of  incubation. 

Not  destructive,  tends  to  heal 
rapidly. 

Edges  sloping,  not  under- 
mined. 

Scanty,  serous  secretions. 

Secretion  not  auto-inoculable. 

Usually  single. 

Generally  indurated ;  some- 
times, rarely  however,  not. 

Glands  indurated,  not  in- 
flamed ;  very  rarely  suppurate, 
and  then  from  causes  apart  from 
syphilis.  Never  furnish  inoc- 
ulable  pus. 

Jonathan  Hutchinson^  declares  the  majority  of  venereal  sores 
to  be  abortive  inoculations^  analogous  to  the  frequent  modified  effects 
of  impure  or  mixed  vaccine  virus,  or  those  of  pure  virus  upon  pro- 
tected persons. 

1  Bassereau,  Ricord,  Fournier,  Geigel,  etc.,  advocate  the  dualist  view.  Hebra  was  a 
unitist.    Jon.  Hutchinson,  1876,  asserted  that  ^'■dualism  is  dead." 

2  Brit.  Med.  Journal.  Aug.  26,  1871. 

8  Pathology  and  Treatment  of  Venereal  Diseases.    Third  edition,  1870. 

4  Surgery,  p.  627.  Philadelphia  edition. 

6  Reynolds'  System  of  Medicines,  Am.  Edition,  Vol.  I.,  p.  424. 


Little  if  any  period  of  incu- 
bation. 

Destructive,  with  tendency  to 
spread. 

Edges  undermined. 

Copious,  purulent  secretions. 

Contagious  and  auto-inocu- 
lable character  of  the  pus. 

Usually  multiple. 

Not  seated  upon  an  indurated 
base. 

Glands  liable  to  become  in- 
flamed; when  so,  they  suppurate 
and  become  a  chancroid  furnish- 
ing inoculable  pus. 


CONSTITUTIONAL    SYPHILIS.  509 

Treatment. — Without  claiming  opportunity  to  have  put  fully 
to  the  test  all  the  clifli;ront  ideas,  my  conviction  remains  strong, 
that  for  all  forms  of  primary  syphilis,  except  the  sloughing  or 
the  extremely  phagethBnic  variety,  mercury  is  the  specific  anti- 
dote. I  have  not  seen  reason  to  helieve  in  the  efficacy,  in  primary 
syphilis,  of  any  other  medicine,  internally  administered. 

Blue  mass,  calomel,  iodide  of  mercury,  etc.,  all  have  the  effect. 
Enough  must  be  given  to  produce  the  impression  of  mercury 
upon  the  system ;  but  decided  salivation  is  not  necessary.  I 
never  positively  salivated  more  than  two  men;  one  who  had  a 
bad  chancre  under  a  phimosis,  and  another  peculiarly  susceptible 
to  ordinary  doses.  A  grain  of  blue  pill  thrice  daily,  or  half  a  grain 
of  calomel  as  often,  or  from  half  to  a  grain  of  iodide  of  mercury 
[F.  169]  twice  a  day  will  do.  The  earlier  it  is  begun  with,  the 
better;  at  least  in  indurated  chancre.  Many  recent  authorities 
urge  that  it  is  not  indicated  in  the  absence  of  induration.  I  would 
give  it  in  any  case  of  doubt. 

Local  treatment  is  also  important.  The  caustic  use  of  nitrate 
of  silver  (some  prefer  the  stronger  potassa  caustic),  used  early, 
may  kill  the  specific  disease  at  the  spot.  To  do  so,  it  must  burn 
out  the  whole  substance  of  the  chancre.  After  such  application, 
astringent  lotions,  as  lime-water,  solution  of  sulphate  of  copper 
(gr.  h  to  gr.  j  in  f.3J),  etc.,  may  be  applied,  washing  the  part  gently 
twice  a  day  with  castile  soap  and  water.  Many  cases  thus  treated 
early,  will  get  well  without  taking  any  mercury.  In  obstinate 
venereal  sores,  however,  sprinkling  the  part  with  powder  of  calo- 
mel is  one  of  the  most  effectual  remedies.  The  calomel  air  or 
vapor  hath  has  been  recommended ;  as  well  as  inunction  with 
mercurial  ointment.  Lewin  and  Bricheteau  use  hypodermic 
injections  of  solution  of  corrosive  sublimate.  Iodoform  (Izard, 
Damon,  Petiteau,  and  Courteau)  has  come  into  use  latterly, 
especially  as  a  local  application  to  venereal  sores.  It  may  be 
employed  in  powder,  ointment,  or  alcoholic  solution  with  glycerin. 
Kicord  (the  leading  authority  in  regard  to  syphilis)  is  reported^  to 
have  arrived  at  the  conclusion,  that  destruction  of  the  infecting 
chancre  does  not,  even  if  effected  early,  prevent  constitutional 
disease.  But  even  if  this  be  so,  the  local  disorder  is  quite  suffi- 
ciently serious  to  be  deserving  of  prompt  and  energetic  measures 
to  deprive  it  of  its  specific  chax'acter. 

Buboes,  if  they  inflame,  may  be  leeched,  and  refrigerated  with 
lead-water,  or  soothed  with  poultices.  When  they  suppurate,  let 
them  be  freely  opened  with  a  bistoury.  When,  afterwards,  they 
refuse  to  heal,  the  surgical  treatment  proper  for  indolent  ulcers 
will  be  suitable  for  them;  besides  the  local  use  of  powder  of 
calomel. 

CONSTITUTIONAL  SYPHILIS. 

Weeks  or  months  after  the  primary  disease,  sec07ulary  syphilis 
may  show  itself.  Once  produced,  although  sometimes  readily 
curable,  it  often  impairs  the  constitution  ifor  life,  and  transmits 
the  taint  to  offspring. 

>  Leloir,  Annales  de  Dermat.  et  de  Syph.,  No.  1,  1880,  p.  69. 
43* 


510  DIATHESES. 

The  affections  belonging  to  secondary  syphilis  are,  peculiar 
copper-colored  eruptions,  rupia  especially ;  warts  about  the  gen- 
itals; ulcers  of  the  throat;  iritis;  loss  of  hair  (alopecia);  affections 
of  the  testicle  or  uterus.     These  last,  as  well  as  periostitis  and 

osseous  tumors  or  nodes,  cu- 
FiG.  123.  taneous  tubercles,  gummata 

(soft,  elastic  tumors,  found 
on  the  skin  and  the  bones, 
and  occasionally  in  the  vis- 
cera), and  chronic  degen- 
erative inflammations  of 
the  brain,  spinal  marrow, 
liver,  spleen,  lungs,  etc. ,  are 
often  called  tertiary  syph- 
ilis. Jonathan  Hutchin- 
son regards  the  secondary 
Syphilitic  Teeth.  Healthy  Teeth.  maladies  as  due  to  blood- 
changes;  the  tertiary,  to  al- 
terations of  tissues.  Although  long  ago  suspected,  Dr.  T.  Reade, 
of  Belfast,  first  proved  (1847)  the  syphilitic  origin,  in  some 
instances,  of  certain  nervous  affections ;  epilepsy,  mania,  hem- 
iplegia, amaurosis,  loss  of  memory,  cranial  neuralgia,  paralysis 
of  sphincters ;  all  resulting  from  syphilitic  disease  affecting  the 
nerve-centres.* 

General  experience  and  opinion  have  asserted  that  constitu- 
tional syphilis  is  not  transmissible  by  inoculation.  Some  modern 
experiments  (Lee,  Walker,  Pelizarri)  have  placed  this  question 
again  "sub  judice."  The  following  statements  (Bryant)  are  now 
generally  accepted: — 

"  A  health}^  woman  marrying  a  man  who  has  had  syphilis,  but 
who  has  lost  all  symptoms  of  it,  may  acquire  syphilis  through  a 
blighted  ovum,  or  a  series  more  or  less  prolonged  of  stillborn 
children,  the  placental  circulation  between  the  foetal  and  mater- 
nal blood  being  the  infecting  medium. 

"A  healthy  woman,  giving  suck  to  a  child  the  subject  of  hered- 
itary syphilis,  may  acquire  the  disease  through  some  fissure  of 
the  nipple,  the  disease,  locally  and  constitutionally,  manifesting 
its  presence  with  all  the  intensity  of  a  primary  inoculation. 

"Again,  the  secretion  of  any  true  syphilitic  sore,  chancre,  mu- 
cous tubercle,  whether  of  the  mouth,  nose,  anus,  vulva,  or  penis, 
is  capable  of  transferring  the  disease  ;  and  the  syphilitic  poison 
may  probably  be  simply  absorbed  by  the  vessels  of  a  part— p%s- 
iological  absorption — without  giving  rise  to  any  local  affection. 
Hunter  believed  this,  and  Lane,  Marston,  and  Lee  have  pub- 
lished observations  that  tend  to  support  the  theory."  There 
seems  no  room  to  doubt  that  a  child  may  inherit  syphilis  from  a 
syphilitic  father,  even  when  the  mother  is  perfectly  healthy  at 
the  time  of  conception. 

In  1872,  at  Vienna,  Dr.  A.  Lostorfer  asserted  his  discovery  of 
certain  small  shining  bodies  in  the  blood  of  syphilitic  patients 
(after  it  had  been  kept  several  days)  which  are  not  present  in  the 

1  See  a  paper  by  Dr.  E.  L.  Keyes,  N.  Y.  Med.  Journal,  November,  1870. 


SYPHII.TS,  511 

blood  of  other  persons.  These  "  syphilitic  corpuscles,"  so  called, 
were,  however,  afterwards  found  by  Strieker  and  others  in  patients 
suffering  with  various  cachectic  allectious. 

Treatment. — Mercury  is  available  in  the  treatment  of  second- 
ary as  well  as  of  primary  syphilis  ;  but  its  power  over  it  is  less 
absolute.  After  jnoderate  trial  of  its  impression  (especially  of 
the  green  iodide  of  mercury  in  ^-  grain  doses,  twice  daily),  iodide 
of  potassium  may  be  given  ;  from  ten  to  thirty  grains  thrice  daily. 
This  is  an  almost  certain  cure  (I  have  never  known  it  to  fail)  for 
syphilitic  "■  77ia«?)(at/sm "  or  bone  pains  with  or  Avithout  nodes. 
Over  ulcers  of  the  throat,  also,  it  has  great  power  ;  as  well  as  over 
purely  syphilitic  affections  of  the  nervous  system.  Such  things, 
however,  often  do  not  stay  cured  ;  they  break  out  again,  as  may 
also  the  cutaneous  eruptions  ;  requiring  the  same  treatment  over 
and  over.  In  some  amemic  cases  iodide  of  iron  will  do  great  good. 
Mercury  and  iron  may  be  given  together  very  well ;  either  the 
two  iodides  or  the  two  percldorides. 

Donovan''s  solution,^  internally,  and  mercurial  ointment  locally, 
are  the  only  additional  remedies  among  many  proposed  and  often 
used,  that  1  think  it  worth  while  to  name  in  our  brief  considera- 
tion of  this  subject.  Dr.  F,  Bumstead  thinks  very  highly  of 
mercurial  inunction,  along  with  the  internal  use  of  iodide  of 
potassium.  The  oleate  of  mercury  (Marshall)  has  become  a 
favorite  with  some  practitioners  for  external  use.  Of  course, 
enfeeblement  of  the  constitution  of  the  patient  may  require  the 
employment  of  generous  diet,  salt  bathing,  change  of  air,  iron, 
quinine,  or  cod-liver  oil. 

Syphilization. — Among  the  most  remarkable  curiosities  of 
medical  history  is  the  attempt  made  to  prevent,  and  even  to  cure, 
syphilis  by  inoculation  with  the  syphilitic  virus.  Auzias  Turenne, 
Sperino  of  Turin,  Broeck  of  Christiania,  and  J.  Z.  Hall  of  St. 
Louis,  Mo.,  have  esj^ecially  urged  their  assertions  of  success  with 
this  process.  The  immunity  is  said,  like  that  of  vaccination, 
to  last  for  life.  Out  of  place  as  it  would  be  to  discuss  it  here, 
it  must  be  said  that,  after  reading  a  good  many  pages  of  the 
evidence,  pro  and  con,  I  do  not  find  that  positive  proof  enough 
has  been  afforded  to  overcome  the  strong  a  liriori  improbability 
of  its  availability. 

It  has  been  fairly  tried  by  eminent  authorities,  such  as  Hebra, 
of  Vienna,'-^  and  abandoned.  Also  those  who  advocate  it  admit 
that  it  is  a  slow  method  of  cure,  as  well  as  far  from  agreeable  ; 
and  as  to  its  prophylactic  use,  few  physicians,  at  all  events,  in  this 
country,  are  likely  to  recommend  it  to  their  patients  instead  of 
avoidance  of  the  cause  of  contamination.  Jonathan  Hutchinson, 
Bodet,  Hardie,  and  others  have  recorded  instances  of  the  recur- 
rence of  syphilis  by  a  second  inoculation  in  the  same  person. 
Kcebner,  of  Berlin,  reports  forty-five  cases  of  this  ;  thirty-seven 
witnessed  by  others,  and  eight  occurring  under  his  own  knowl- 
edge. 


1  Liquor  Hydrargyri  et  Arsenici  lodidi.    Dose,  3  to  5  drops. 
«See  Phila.  Med.  Times,  Oct.,  1870,  p.  11, 


512  DIATHESES. 


GONOEBHCEA. 


Very  few  words  must  suffice  us  upon  this  topic,  Gronorrhoea  is 
a  specific  urethritis;  in  tlie  female,  also,  vaginitis  ;  produced  by 
impure  sexual  congress.  Its  symptoms  are,  pain  and  soreness, 
redness  and  swelling  of  the  penis,  with  early  and  continued 
suppurative  discharge.  Burning  pain  on  passing  water,  and 
chordee,  or  painful  rigidity  of  erection,  are  the  principal  causes  of 
suffering,  while  the  patient  is  at  rest.  Walking  about  aggravates 
very  much  the  soreness  and  pain. 

Urethritis,  or  balanitis  (inflammation  of  the  glans  penis),  may 
occasionally  be  brought  on  by  contact  with  the  matter  of  leucor- 
rhoea  or  the  menstrual  discharge.  No  perceptible  difference 
exists  in  the  symptoms  in  this  case  from  gonorrhoea ;  but  the 
latter  is  more  obstinate,  and  is  itself  directly  contagious.  Such 
non-specific  urethritis  is,  moreover,  a  very  rare  disorder. 

The  period  of  incubation  of  gonorrhoea  is  sometimes  but  a  day  ; 
seldom  many  days.  Its  duration  is  generally  from  ten  days  to 
three  weeks.  But  a  gleet,  or  chronic  discharge,  more  or  less 
muco-purulent  without  active  inflammation,  may  be  left  behind, 
of  indefinite  continuance. 

Sy77ipathetic  non-suppurating  bubo  may  attend  gonorrhoea ;  so 
may  also  orchitis,  or  inflammation  of  the  testicle.  Gonorrhoeal 
rheumatism  is  sometimes  met  with,  ascribed  to  a  metastasis  of 
the  local  affection  to  some  of  the  joints.  Pyaemia  sometimes 
(P.  Hewett)  follows  gonorrhoea,  though  very  rarely. 

Treatment. — At  first,  during  the  height  of  the  inflammation, 
rest  in  bed,  low  diet,  Epsom  salts,  and  free  draughts  of  flaxseed 
tea,  comprise  the  best  treatment.  It  is  true  there  is  a  period  at 
the  end  of  incubation,  when  the  symptoms  are  just  commencing, 
when  abortive  treatment  may  be  practised  ;  as  by  a  strong  injec- 
tion of  nitrate  of  silver  (gr.  vj  to  gr.  x  in  fgj)  into  the  urethra. 
This  is  a  bold  and  uncertain  measure,  however.  Kuchenmeister, 
of  Dresden,  asserts  (1880)  that  lime-water  (one  part  to  four  of 
water),  repeated  several  times  in  a  day,  will  safely  abort  gonor- 
rhoea. Dr.  W.  W.  Cheyne  ^  uses  bougies  of  cocoa  butter,  mixed 
with  iodoform  and  oil  of  eucalyptus  (iodof.  gr.  v,  ol.  eucalypt. 
•"K.  X  ;  butyr.  cac.  gr.  xl).  Other  practitioners  also  employ  bougies 
of  butter  of  cacao,  or  gelatin  and  glycerin,  with  which  diflferent 
remedies  are  incorporated;  as  gallic  or  tannic  acid  (gr.  j),  subnitrate 
of  bismuth  (gr.  x. ),  nitrate  of  silver  (gr.  i  to  |),  acetate  of  lead 
(gr.  i  to  gr.  j ),  sulphate  of  zinc  (gr.  J  to  gr.j),  extract  of  belladonna 
(gr.  j  to  ii). 

Bathing  the  penis  frequently  in  warm  water  is  very  soothing  to 
the  pain  and  soreness.  Chordee  may  be  treated  by  that  means, 
and  by  suppositories  of  opium  and  cocoa  butter.  A  pill  of  cam- 
phor and  belladonna  (camphor  five  grains,  ext.  belladonnse  half 
a  grain)  at  bedtime  will  be  useful  in  preventing  chordee. 

As  soon  as  the  activity  of  the  urethritis  has  subsided,  injections 
may  be  used ;  of  nitrate  of  silver  (gr.  j  to  gr.  iv  in  fgj),  acetate 
or  subacetate  of  lead  (subacetate,  gr.  x  in  fgj),  sulphate  of  cop- 

iBrit.  Med.  Journal,  vol.  ii.,  1880,  p.  124. 


RCROFTTT.  A.  518 

per  (tcr.  j  in  f,\j),  sulphate  of  zinc  {<^v.  ij  in  f,\i),  or  chloride  of 
zinc  (i^r.  j  in  f,\i).  (xlycorin  may  be  added  to  the  water  in  eith(;r 
of  these  solutions  with  advantage.  Glycerole  of  tannin  [F.  205] 
is  also  a  useful  preparation. 

Copaiba  and  eubebs  are,  time  out  of  mind,  medicines  for  gon- 
orrluea.  Without  any  specijic  antidotal  properties,  they  come  in 
well,  one  after  the  other;  first  the  copailta,  and  then  the  eubebs 
(in  half-tiuidrachm  doses  of  the  former,  in  mucilage,  and  ten  to 
twenty-grain  doses  of  the  latter),  when  the  inflammation  is  sub- 
siding [F.  174,  175]. 

For  yleet,  which  is  often  very  annoying,  local  treatment,  with 
regulation  of  the  diet  (avoiding  stimulants  and  condiments),  must 
be  depended  on.  Injections,  of  the  same  character  as  those  above 
alluded  to,  may  be  repeated.  Should  they  fail,  a  bougie,  smeared 
with  an  astringent  ointment,  should  be  introduced  every  day  or 
two,  and  left  in  the  urethra  for  ten  or  twenty  minutes.  Ointment 
of  nitrate  of  mercur}^,  of  carbonate  of  lead,  spermaceti  ointment, 
and  ointment  of  nitrate  of  silver,  are  all  reconmiended.  A  flexible 
bougie,  of  cacao  (cocoa)  butter  will  irritate  the  least.  Very 
obstinate  cases  have  sometimes  been  cured  by  the  introduction 
of  solid  nitrate  of  silver  by  the  porte-caustique. 

Examination  with  the  endoscope  (introduced  for  specular  exam- 
ination of  the  urethra)  may  detect  the  exact  spot  which  is  the 
seat  of  the  irritation  and  discharge.  Blistering  the  perineum  is 
practised  by  some  for  gleet.  Constitutional  treatment  by  tonics 
may  be  called  for  when  general  relaxation  maintains  the  com- 
plaint. 

SCEOFULA. 

Prof.  Aitken^  defines  (scrofulosis  or)  tuberculosis  as  follows : 
"A  particular  morbid  condition  of  the  system,  attended  [gener- 
ally] by  a  persistent  increase  of  temperature,  followed  by  a  con- 
tinuous wasting  of  the  body  and  the  growth  of  a  substance  in 
various  tissues  and  organs,  especially"  the  lungs,  to  which  the 
name  of  tubercle  or  tuberculous  matter  has  been  applied.  These 
phenomena  are  associated  with  peculiarities  of  outward  appear- 
ance during  life,  and  liability  to  certain  diseases  termed  scrofulous, 
such  as  swellings  of  lymj^hatic  glands  and  of  joints,  carious  ulcer- 
ations of  bones,  frequent  and  chronic  ulcerations  of  the  cornea, 
ophthalmia,  abscesses  and  cutaneous  pustular  eruptions,  persistent 
swelling  and  catarrh  of  the  mucous  membrane  of  the  nose,  and 
characteristic  thickening  and  swelling  of  the  upper  lip, — lesions 
which,  while  they  are  distinguished  by  mildness  of  symptoms, 
are  peculiarly  persistent,  and  follow  the  application  of  exciting 
causes  which  would  have  no  eflect  on  a  healthy  person." 

Scrofula  is  the  term  applied  commonly  to  those  of  the  above- 
named  local  aliections  involving  (most  frequently  in  rather  early 
life)  the  glands,  bones,  nose,  ears,  and  eyes.  The  tubercular 
diathesis  has  been  already  sufficiently  consiclered  for  our  purpose 

1  Science  aud  Practice  of  Medicine,  vol.  ii.,  p.  188.  As  remarked  already  under  Gen- 
eral Pathology,  this  identification  of  tuberculosis  with  scrofulosis  is  not  assented  to  by 
all  pathologists.    I  believe,  however,  that  it  is  essentially  correct. 

2H 


514:  DIATHESES, 

and  space.  (See  General  Pathology.)  A  very  few  words  of  a 
practical  bearing  must  be  added. ^ 

The  causes  of  scrofula  are,  chiefly,  hereditary  transmission,  and 
deprivation  of  pure  air.  The  former  is  well  known  to  all.  Baude- 
locque,  McCormick,  and  Greenhow,  among  others,  have  proved 
the  latter  most  thoroughly.  All  depression  of  the  system  by  low 
living,  such  as  insufficiency  of  food  and  warmth,  dampness,  etc., 
will  promote  it.  It  has  been  imagined,  not  proved,  that  the 
syphilitic  taint  of  constitution  may  glide  into  it. 

In  treatment  of  scrofula  in  any  of  its  forms,  but  particularly 
in  chronic  enlargements,  with  or  without  cheesy  softening,  of  the 
lymphatic  glands  (of  the  neck,  armpit,  or  groin),  iodine  has  had 
general  confidence  [F.  176],  It  is  not,  however,  infallible. 
Iodide  of  ammonium  (dose  3  grains)  is  now  coming  under  trial. 
Iodized  milk  (Hagar)  is  said  to  be  very  available ;  one  part  of 
iodine  dissolved  in  ten  parts  of  alcohol,  and  mixed  with  ninety 
parts  of  fresh,  warm  cow's  milk.^  The  external  application  of 
iodine  to  tumors,  scrofulous  or  other,  "to  produce  absorption," 
will  very  frequently  disappoint.  I  am  not  sure  that  it  has, 
locally,  any  effect  but  as  *  stimulant  or  irritant.  That  may 
sometimes  be  useful.  Mr.  Furneaux  Jordan  asserts^  that  counter- 
irritation  by  iodine,  applied  a  short  distance  from  the  enlarged 
glands,  as  at  the  back  of  the  neck,  has,  in  his  hands,  never  failed 
to  be  followed  by  their  reduction. 

Dr.  J.  Lewis  Smith  advises  the  application  to  the  enlarged 
glands  of  a  rather  weak  ointment  of  iodine,  to  allow  absorption 
without  irritation.  Mr.  Henry  Power,  of  St.  Bartholomew's 
Hospital,  London,  has  found  extract  of  belladonna,  internally, 
and  the  local  application  of  atropia,  important  remedies  in  stru- 
mous ophthalmia,  in  children. 

God-liver  oil  is  also  an  anti-strumous  remedy  of  great  power ; 
and  one  more  readily  taken  by  the  young  than  by  adults,  gen- 
erally. Iron  may  be  serviceable  in  many  debilitated  scrofulous 
eases.  Sea  bathing  and  sea  air  are  among  the  best  of  remedies. 
Good  diet  is  indispensable.  The  dietetic  salt  of  Dr.  Lankester, 
prepared  by  adding  to  common  salt  small  quantities  of  phos- 
phoric acid,  sulphuric  acid,  lime,  potassium,  and  iron,  may  have 
some  advantages,  and  is  worthy  of  trial.  The  same  may  be  said 
of  ferruginous  chocolate. 

Moleschott,  of  Turin  (1878),  has  reported  several  years'  favor- 
able experience  with  iodoform  in  promoting  the  removal  of  scrof- 

1  Lymphadenoma,  the  adinie  of  Trousseau,  pseudo-letikcemia,  or  "  Hodgkin's  disease  " 
of  the  glands  (Medico-Chirurg.  Transactions,  vol.  xvii.),  appears  not  to  be  identical  with 
scrofula.  "  Hodgkin  observed  it  first  in  the  mesenteric  glands,  but  any  or  all  may  be 
affected.  In  it  the  glands  become  very  much  enlarged,  even  to  the  size"  of  an  egg,  and 
apparently  more  numerous;  they  present  a  smooth  external  appearance,  and  have  a 
soft  semi-fluctuating  elastic  feel.  On  section  the  surface  of  the  gland  presents  a  smooth, 
bloodless,  semi-transparent,  loose,  succulent  structure;  microscopically  it  is  made  up 
of  glandular  tissue  and  abundance  of  fibro-nucleated  tissue ;  it  is  of  a  tough,  leathery 
consistence,  and  exudes  a  clear  serous  fluid ;  the  tumors  are  always  free,  each  being 
separable  from  the  others."    (Bryant's  Surgery.) 

Mycosis  is  a  name  given  by  some  pathologists  (Malassez,  Gilot,  Landouzy)  to  an  affec- 
tion of  the  glands  of  a  similar  nature  to  this.  See  a  case  reported  by  Debove ;  Le  Mouve- 
meni  Medicate,  October,  1872. 

2  Medical  Press  and  Circular,  Jan.  1.5,  1871. 

3  Med.  Times  and  Gaz.,  Aug.  20, 1870. 


RICKETS.  615 

ulous  glandular  enlargements.  lie  prefers  its  local  application 
(although  giving  it  also  iuteriially  in  one-grain  doses),  by  means 
of  a  combination  of  one  part  of  iodoform  with  fifteen  of  elastic 
collodion ;  or  an  ointment  of  the  same  strength.  This  may  be 
brushed  over  the  glandular  tumors  with  a  eamel's-hair  pencil  at 
night,  and  washed  off  with  soap  and  water  in  the  morning.  I 
have  found  hcnzocUcd  vaseline  a  good  vehicle  for  iodoform,  lessen- 
ing although  not  destroying  its  unpleasant  odor;  which  is  also 
said  to  be  removed  by  the  addition  to  it  of  balsam  of  tolu,  or  by 
tincture  of  musk  (Tt^'  to  §j). 

Massage,  especially  with  oleaginous  inunction,  is  likely  to  be 
beneficial  in  the  more  torpid  scrofulous  constitutions.  (See 
brassage,  in  Part  I.,  Section  III.) 

Kapesser^  reports  the  beneficial  use  of  regular  periodic  inunc- 
tion with  soft  soap  in  treatment  of  glandular  enlargements. 

The  Ioc((l  treatment  of  so-called  scrofulous  affections  is  to  a 
great  extent  surgical.  Slowly  softening  glands  may  sometimes 
be  cut  out.  Scrofulous  periostitis,  threatening  caries,  I  have 
seen  arrested  by  free  application  of  cerate  of  carbonate  of  lead 
over  the  aftected  bone.  The  legs  are  most  frequently  the  seat 
of  such  disease ;  but  it  may  attack  any  of  the  long  bones. 
Removal  of  diseased  or  necrosed  portions  is  to  be  recommended 
rarely,  unless  they  are  loosened.  Extensive  resections  should  be 
very  exceptional. 

RICKETS. 

Synonym. — Bachitis.  Infants  upon  learning  to  walk  show  the 
cachexia  to  which  this  name  is  given,  by  yielding  of  the  bones, 
with  muscular  debility,  and  general  failure  of  nutrition.  The 
bones  are  brittle  from  imperfect  development ;  the  spine  is  apt 
to  become  curved  and  the  limbs  crooked.  The  occipital  bone 
and  ribs  are  apt  to  undergo  irregular  enlargement.  The  teeth 
are  backward  in  coming,  and  fall  out  with  early  decay.  Tender- 
ness of  the  surface  of  the  body,  and  irritability  of  the  nervous 
system,  also  exist.  Laryngismus  and  convulsions  are  among  the 
not  uncommon  symptoms. 

Dr.  C.  C.  Ritchie'^  has  shown  that  an  important  diagnostic  sign 
between  rickets  and  tuberculous  disease  is,  that  the  increase  of 
temperature,  especially  in  the  evening,  common  in  tuberculosis, 
is  absent  in  rickets. 

Rachitis  does  not  appear  to  be  hereditary.  Its  most  frequent 
cause  is  insufficient  or  unsuitable  food. '^ 

English  medical  authors  speak  of  rickets  as  a  very  common 
disorder  in  Great  Britain.  It  is  certainly  not  so  in  America. 
Practitioners  of  large  experience  see  very  little  of  it.  In  nine 
years,  endiiag  with  1870,  the  mortality  records  of  Philadelphia 
reported  but  two  deaths   from   rickets.      Meigs   and   Pepper* 

1  Berliner  Klin.  Wochensclir.,  Feb.  11,  1878. 

2  Med.  Times  and  Gazette,  Jan.  7,  1871. 

3  See  an  elaborate  paper  l)y  Dr.  J.  S.  Parry,  Am.  Journal  of  Medical  Sciences,  April, 
1872.  See  also  the  article  "  Rickets"  by  Professor  Aitken,  in  Reynolds'  System  of 
Medicine,  American  edition.  Vol.  I. 

*  Treatise  on  Diseases  of  Children,  p.  631. 


516  DIATHESES. 

remark,  "we  escape  to  a  great  extent  the  ravages  of  this  fatal 
disease." 

Treatment. — Hygienic  measures  are  of  the  first  consequence. 
"Well-aired  rooms,  warm  salt  bathing,  milk  or  beef-tea  diet,  cod- 
liver  oil,  iron,  and  phosphate,  lacto-phosphate^  [F.  257j,  or  hypo- 
phosphite  of  calcium,  all  have  their  value. 

CARIES  OF  THE  SPINE. 

Synonym, — PoWs  Disease. 

In  scrofulous  children  of  either  sex,  between  two  and  fifteen 
years  of  age,  sometimes  without,  but  oftener  after,  a  fall,  blow, 
or  other  mechanical  injury,  caries  of  the  body  of  one,  or  occa- 
sionally two  or  three  of  the  vertebrae  may  occur.  The  dorsal 
region  is  most  frequently  attacked. 

Symptoms. — Pallor,  debility,  pain  in  the  abdomen,^  in  sudden 
and  severe  paroxysms ;  irritability  of  temper,  stooping  forward 
in  walking,  rigidity  of  muscles,  a  cautious,  gliding  gait,  to  avoid 
concussion  of  the  spine ;  loss  of  appetite,  swelling  of  the  belly, 
uneasy  sleep,  hurried  or  impeded  respiration ;  tenderness  of  the 
spine  on  pressure ;  an  angular  deformity  or  backward  projection 
of  a  portion  of  the  spine ;  paralysis  in  various  degrees,  abscesses 
of  the  back,  discharging  externally  or  by  the  lungs,  bowels, 
vagina ;  or,  the  pus  entering  the  hip-joint. 

Treatment. — Dr.  Henry  G.  Davis,^  of  IS'ew  York,  claims,  and 
I  believe  with  reason,  to  have  introduced  an  important  improve- 
ment into  the  treatment  of  caries  of  the  spine.  Of  the  older 
methods,  the  best  idea  was  rest  to  the  back,  with  careful  efforts 
at  extension ;  and,  especially  in  this  country  by  the  late  Dr. 
John  K.  Mitchell,  support  (by  means  of  corsets)  dependent  upon 
attachments  quite  outside  of  the  body.  Dr.  Davis,  reasoning 
upon  the  fact  that  the  bodies  of  the  vertebrte  are  the  seats  of  the 
destructive  process,  aims  at  separating  these,  throwing  all  the 
weight  upon  the  oblique  processes.  The  spine  is  relieved  then 
by  strengthening  rather  than  extending  it. 

An  apparatus  of  Dr.  C.  F.  Taylor  carries  out  this  and  other 
rational  principles  of  treatment  very  well.  It  is  thus  described  :* 
"A  broad  band  passes  around  the  trunk  low  down,  so  low  that 
in  front  it  almost  touches  the  thighs  in  sitting.  It  passes  just 
above  the  pubes  and  entirely  below  the  abdomen,  so  that  the 
abdomen  is  sustained  upward,  instead  of  being,  as  in  most  instru- 
ments, pressed  downward.  There  are  two  pieces  or  levers  passing 
up  the  back,  not  over  the  spine,  but  each  side  of  it,  so  that  it  is 
firmly  held  from  lateral  deviations.  At  the  top  is  a  cross-piece 
in  the  form  of  two  T's  with  the  small  ends  united.  The  object 
of  this  arrangement  is  that  the  straps  may  pass  directly  forward 
and  around  the  arms,  and  thus  prevent  a  great  loss  of  force  by 

1  Dusart  and  Blache,  Bull.  Gen.  de  Therapeutique,  July,  30, 1868 ;  also,  a  paper  by  Dr. 
B.  W.  MacCready,  New  York  Med.  Journal,  June,  1871. 

2  Dr.  B.  Lee  (Angular  Curvature  of  the  Spine,  1867)  speaks  of  gastralgia  as  an  initial 
symptom. 

3  Conservative  Surgery,  1867.  Dr.  Davis's  first  publication  on  the  subject  was  in 
the  Boston  Medical  and  Surgical  Journal,  August,  1852. 

*  Angular  Curvature  of  the  Spine,  by  Dr.  B.  Lee,  p.  70. 


COXALGIA.  517 

diacconal  action ;  and  also  that  thoy  shall  toucth  the  person  only 
whcn^  the  pressure  is  needed',  namely,  on  the  forward  part  of  the 
shoulders.  At  a  part  of  the  instrument  opposite  the  seat  of  the 
disease,  the  point  where  we  make  our  ful(;rum,  the  pads  are 
placed.  Tlu'S(^  are  made  of  chamois  skin,  or  Canton  llannel,  and- 
are  tilled,  not  with  cotton,  which  soon  packs  and  becomes  hard, 
but  with  lon-ij,  elastic  African  or  East  Indian  wool,  which  has  no 
feltini^  qualities.  Tiiese  pads  are  removable  when  they  become 
compacted.  The  shoulder-straps  and  bands  around  the  hips  are 
likewise  provided  with  removable  pads  to  protect  the  skin  against 
pressure  and  abrasion. 

"  It  will  be  seen  that  the  instrument,  like  the  spine  itself,  acts 
like  a  double  lever  with  a  common  fulcrum  at  the  curvature  ;  this 
action  is  directly  backward  at  the  hips  and  shoulders,  and  directly 
forward  at  tlie  middle  of  the  back,  or  wherever  the  diseased  part 
is  located.  .  .  .  The  instrument  is  provided  with  several  hinges, 
stn})  hinges  in  frnut.  but  free  to  bend  backwards,  which  allows  the 
most  unrestrained  use  of  th.'  muscles  of  the  back  .  .  .  useful  in 
causing  the  development  of  the  spinal  muscles  instead  of  binding 
them  up  and  causing  their  atrophy,  as  results  from  the  use  of 
instruments  which  prevent  muscular  action." 

Dr.  Say  re's  name  has  become  especially  connected  with  the  use 
of  the  jacket,  made  of  bandages  soaked  in  plaster  of  Paris,  and 
fitted  to  the  body  by  their  application  while  the  patient  is  sus- 
pended (so  as  to  extend  the  spinal  column)  by  the  axilla  and  head 
in  a  framework  constructed  for  the  purpose.  W.  Adams,  of 
London,  Dr.  B.  Lee,  and  others  have  used,  instead,  a  porous  felt 
jacket,  similarly  applied.  Di\  D.  H.  Agnew'  prefers  a  jacket 
made  of  leather,  strengthened  by  thin  strips  of  steel. 

Constitutional  treatment,  by  fresh  air  and  sunshine,  nourishing 
diet  and  cod-liver  oil,  iron,  or  other  tonios,  as  well  as  purgatives 
(if  required,  as  they  are  in  most  cases)  must  be  added,  of  course, 
to  mechanical  means.  Cures  are  thus  sometimes  efiected  in  cases 
once  thought  hopeless. 

Lateral  curvature  of  the  spine  is  very  different,  mostly  depend- 
ing upon  muscular  weakness  or  inequality  of  development.  Bad 
habitual  positions  often  cause  it.  Training  the  subject  of  it  to 
,  icse  his  muscles  properly,  and  thus  develop  and  strengthen  them, 
must  be  the  leading  idea  in  its  treatment,  apparatus  here  being 
quite  secondary,  though  perhaps  sometimes  temporarily  needful. 


COXALGIA. 

Synonyms. — Morbus  Coxarius ;   Hip-Disease. 

Though  regarded,  like  spinal  caries,  as  rather  a  "  surgical " 
subject,  a  few  words  may  not  be  out  of  place  upon  this  theme 
also.  Its  etiology  appears  to  be  like  that  of  disease  of  the  spine  ; 
a  constitutional  tendency,  tubercular  or  scrofulous,  acted  upon 
in  many,  though  far  from  all  cases,  by  a  local  injury.  Intiam- 
mation  of  the  hip-joint  occurs,  in  some  instances  acute  and  vio- 

'  Principles  and  Practice  of  Surgery,  Vol.  \:, 
44 


518  DIATHESES. 

lent,  oftener  active  only  at  first  and  to  a  moderate  degree  ;  not 
rarely  insidious  in  approach. 

Symptoms  of  the  most  characteristic  kind  are,  pain  in  the 
knee,  without  any  other  sign  of  disease  about  that  part ;  and  a 
limping  gait,  the  knee  being  bent,  the  child  treading  only  on  the 
toes  of  the  affected  limb.  Spasmodic  contraction  of  the  muscles 
causes  fixation.of  the  joint.  Examining  the  hip-joint,  it  is  found 
that  pressing  the  head  of  the  thigh-bone  into  it  gives  pain. 
Atrophy  of  the  muscles  over  the  hip  may  follow.  G-eneral 
weakness  and  emaciation,  with  other  symptoms  of  the  scrofu- 
lous cachexia,  usually  attend.  Suppuration  in  the  joint,  with 
chronic  abscesses,  ulceration  of  the  cartilages,  subluxation  of 
the  femur,  and  caries  of  the  bones,  with  hectic  fever  and  pro- 
gressive debility,  occur  in  severe  cases. 

Treatment. — Physick's  celebrated  treatment  was,  absolute  rest 
of  the  joint  by  means  of  a  carved  splint,  passive  exercise  in  the 
open  air,  in  a  carriage,  or,  if  a  young  child,  in  arms— and  sys- 
tematic purgation  with  jalap  and  cream  of  tartar.  To  this,  with 
less  stress  upon  the  not  at  all  necessary  purging.  Dr.  H.  G.  Davis 
has  added  the  use  of  continued  elastic  extension  of  the  limb,  so  as 
to  relieve  the  joint  of  the  pressure  of  the  head  of  the  bone  in  its 
socket,  caused  by  the  contraction  of  tlie  muscles.  This  con- 
tinued elastic  extension  may  be  obtained  in  bed,  by  adhesive 
plaster  strips,  to  which  is  suspended,  by  a  cord  and  pulley,  a 
weight,  proportioned  to  the  amount  of  power  wliich  the  muscles 
display,  and  tested  by  the  comfort  secured  by  it  to  the  patient. 
Out  of  bed,  a  splint  may  be  applied,  maintaining  elastic  exten- 
sion by  a  perineal  band,  best  made  of  adhesive  plaster,  spread 
(as  proposed  by  Dr.  Davis)  upon  twilled  material,  and  kept  for  a 
while  before  use,  so  as  to  lose  its  unctuous  property  and  remain 
more  securely  in  place. 

Another  mode  of  treatment  (J.  C.  Hutchison)^  is  by  extension 
of  the  joint,  without  absolute  rest.  This  may  be  effected  by 
placing  a  high-soled  shoe  upon  the  foot  of  the  sound  limb,  and 
letting  the  patient  walk  about  for  two  or  three  hours  daily  with 
crutches.  Several  practitioners,  prefer  along  witli  this,  to  secure 
the  joint  from  much  movement  by  a  posterior  splint,  or  silicate 
of  sodium  immovable  bandage. 

Simple  inflammation  of  the  hip-joint  may,  of  course,  follow  an 
injury;  and  may  find  relief  in  a  comparatively  brief  time,  from 
rest,  with  local  antiphlogistic  measures,  as  cups,  a  blister,  etc. 

N^MIA. 

Something  has  been  said  upon  this  subject  under  General 
Pathology. 

The  causes  of  anaemia  are,  most  often,  either,  1.  Loss  of  blood, 
from  disease  or  injury  causing  hemorrhage.  2.  Excessive  suck- 
ling in  a  mother,  or  wet-nurse.  3.  Severe  or  protracted  diar- 
rhoea, or  (more  rarely)  leucorrhcea.  4.  Typhoid  or  some  other 
form  of  fever.     5.  The  malarial  influence,  sustained  for  a  con- 


1  Amer.  Journal  of  Med.  Sciences,  January,  1879  ;  Phil. Med.  Times,  May  7,  1881. 


AN  JEM!  A.  519 

siderable  time.  G.  Deficiepcy  of  food,  light,  warmth,  or  fresh 
air. 

Anreinic  symptoms  are  pallor,  slenderness  of  figure,  dcbilit^^, 
nervous  excitability,  cardiac  palpitation.  Antemic  murmurs  in 
the  heart  and  aorta  have  be(m  mentioned  under  Semeiologij. 

In  the  treatment  of  antemia,  (jood  did.,  jmre  ah%  and  irrm  or 
cod-liver  oil  are  the  essentials.  Of  the  preparations  of  iron, 
numerous  as  they  are,  I  have  found  the  most  satisfactory  results 
from  the  tincture  of  the  chloride,  tbe  pill  of  the  carbonate  (Val- 
let's  mass),  the  iodide  (syrupus  ferri  iodidi),  the  phosphate,  and 
in  children,  the  citrate  [F.  202,  20:5,  204,  205].  Goodhart,  Fother- 
gill,  and  others  bave  observed  that,  as  anteniia  promotes  dilata- 
tion of  the  heart,  care  must  be  taken  with  autemic  persons,  to 
avoid  much  exertion ;  and,  if  symptoms  of  weak  heart  appear, 
digitalis  may  be  given  along  with  iron.  Dr.  Aitken  speaks  very 
higbly  of  the  value  of  a  combination  designated  as  the  "•  syrup 
of  the  phosphates  of  iron,  quinine,  and  strychnia."  This  form- 
ula will  be  given  at  the  end  of  the  book  [see  F,  213] . 

Progressive  Pernicious  Anaemia. — Under  this  name,  Biermer, 
1871,  described  a  form  of  anaemia  not  accounted  for  by  any  of 
the  ordinary  causes  of  such  a  condition.  Otherwise  named,  the 
same  malad.y  had  been  before  mentioned  by  Andral  (1823),  Addi- 
son [idinpathic  ansemia),  Wilks,  Zenker,  and  Wagner,  Lebert 
has  called  it  essential  anaemia. 

Symptoms. — Mostly  with  a  gradual  approach,  this  affection  is 
marked  by  extreme  pallor,  or  a  dusky  yellowness  of  complexion ; 
debility ;  impairment  of  digestion  and  irritability  of  the  stomach ; 
palpitation  of  the  heart;  cardiac  systolic  murmurs  and fremisse- 
ment  cataire;  dyspnoea  and  a  tendency  to  fainting  on  slight  exer- 
tion. Emaciation  is  not  extreme ;  it  may  be  very  moderate  in 
proportion  to  the  aneemia  and  debility.  Swelling  of  the  feet  and 
legs  is  common  at  a  late  stage.  Hemorrhages  are  apt  to  occur, 
from  the  nose,  gums,  bronchial  raucous  membrane,  uterus,  or 
under  the  skin  {petechice,  vibices,  ecchymoses).  Betinal  hemor- 
rhages, producing  blindness,  have  been  observed  (with  the  aid 
of  the  ophthalmoscope)  in  several  cases.  Toward  the  end  of  the 
attack,  fever  is  almost  always  present. 

Morbid  Anatomy  and  Pathology. — Biermer,  Immermann,'  and 
others  have  insisted  that  we  should  exclude  from  the  list  of  cases 
of  this  disorder  all  those  in  which,  after  death,  lesions  are  dis- 
covered such  as  are  ordinarily  known  to  be  associated  with 
anaemia ;  as  enlai-gement  of  the  spleen,  disease  of  the  lymphatic 
glands,  and  morbid  alterations  of  the  marrow  of  the  bones.  This 
appears  to  me  to  be  too  arbitrary  an  exclusion.  The  question, 
hardly  yet  finally  decided,  is,  whether  there  is  a  group  of  cases 
of  progx-essive  anaemia  whose  clinical  history  is  sufficiently  pecu- 
liar and  constant  for  them  to  receive  a  distinctive  nosological 
name ;  and  with  this  question,  of  course,  that  of  their  causation 
is  closely  connected. 

Fatty  degeneration  of  the  heart  has  been  (first  by  Wilks)  a  num- 
ber of  times  observed.     Changes  in  the  marrow  of  the  hones  have 

1  Ziemssen's  Cyclopaedia  of  Medicine,  article  Progressive  Pernicious  An&emia. 


520  DIATHESES. 

been  found  by  Eichhorst,  Gardner,  Osier,  Fede,  Cohnheim,  Pep- 
per,' Litten,  and  others.  Eichhorst  described  as  microcytes  cer- 
tain minute  nucleated  red  corpuscles  in  the  marrow,  sometimes 
also  seen  in  the  blood.  Neumann's  larger  nucleated  "  embryonic 
corpuscles  "  were  also  seen  in  the  marrow  by  Gardner  and  Osier, ■^ 
In  some  cases  of  idiopathic  anaemia,  however,  Lepine,  Burger, 
and  Quincke  have  found  the  bone-marrow  free  from  disease. 
Enlargement  of  both  the  spleen  and  the  liver  were  reported  in  a 
marked  case  by  Eosenstein.* 

Changes  in  the  blood  are,  after  all,  most  characteristic.  It  is, 
during  life,  paler  and  thinner  than  healthy  blood.  The  number 
of  the  red  corpuscles  is  reduced  from  one-fourth  to  one-twelfth 
of  their  normal  proportion  ;  and  they  vary  also  in  size,  and  often 
present  irregularity  of  outline.  The  white  corpuscles  are  not 
ahnormally  increased;  they  may  be  even  diminished.  The  vol- 
ume of  the  blood  generally  throughout  the  body  is  believed  to  be 
considerably  lessened. 

Brigidi,*  in  one  case,  ascertained  that  the  coeliac  ganglia  were 
morbidly  altered,  fatty  and  pigmentary  degeneration  having 
taken  place  in  their  nerve-cells. 

Causation. — No  constant  relation  of  this  disease  to  sex  has  yet 
been  established  ;  although  pregnancy  (especially  rapidly  repeated 
pregnancies)  obviously  predisposes  to  it.  Nor  is  it  certain  that 
one  age  is  more  liable  to  it  than  another,  except  that  it  has 
scarcely  been  met  with  in  persons  under  twenty  years  of  age, 
and  rarely  in  those  of  advanced  age.  Hemorrhages,  exhausting 
acute  or  chronic  maladies  of  various  kinds,  and  prolonged  mental 
anxiety  or  trouble,  are  among  the  most  notable  influences  predis- 
posing to  it.  Yet,  in  a  large  number  of  instances,  no  such,  or 
any  other,  sufficient  causation  can  be  ascertained  for  it ;  espe- 
cially for  the  progressive  and  obstinate  character  which  belongs 
to  it. 

Diagnosis. — Pernicious  anaemia  resembles  most,  leucocythcemia 
(leukaemia),  psewZo-Zezii-oemia  or  Hodgkin's  disease,  chlorosis,  and 
Addison''s  disease  (melasma  supra-renalis). 

From  leucocythsemia  those  cases  at  least  are  clearly  distin- 
guished in  which  tliere  is  enlargement  neither  of  the  spleen  nor 
of  the  lymph-glands,  tenderness  on  pressure  of  the  sternum,  ribs, 
or  other  bones,  or  actual  increase  of  the  number  of  the  white 
blood^corpuscles  beyond  their  normal  proportion  to  the  quantity 
of  blood.  From  pseudo-leukEsmia  we  may  separate  pernicious 
anaemia  by  the  absence  of  that  general  and  persistent  enlarge- 
ment of  the  lymphatic  glands  which  belongs  to  Hodgkin's  dis- 
ease. Pepper  has  expressed  the  opinion  that  pernicious  anaemia 
is  simply  "myelogenous  pseudo-leukaemia." 

Chlorosis  is  almost  always  an  affection  of  females  near  the  time 
of  puberty.  In  it,  as  a  rule,  there  are  no  dropsical  effusions,  no 
hemorrhages,  and  no  fever.  It  is,  moreover,  nearly  always  sus- 
ceptible of  improvement  and  cure  under  appropriate  treatment ; 

1  Amer.  Jour.  Med.  Sciences,  April,  1877. 

2  Canada  Med.  and  Surg.  Journal,  March,  1877 ;  and  Canada  Journal  of  Med.  Sciences, 
May,  1881. 

*  Berliner  Klin.  Wochenschrift,  Feb.  26, 1877.  <  Lo  Sperimentale,  May,  1878. 


CHLOROSIS.  521 

lis  potnicious  ansemia  is  net.  The  latter  is  distinguislied  from 
Addi.son's  disease  ])y  the  absence  of  bronze  discoloration  of  the 
skin,  the  more  extreme  aniemia  with  less  emaciation,  the  hemor- 
rhages, and  the  fever. 

Prognosis. — It  has  been  held  to  be  characteristic  of  this  affec- 
tion to  be  extremely  intractable,  if  not  incural)le.  While  usually 
progressive,  with  a  duration  of  from  six  weeks  to  six  months,  cases 
are  recorded  in  which  reynissions,  lasting  even  for  months,  have 
given  a  deceptive  hope  of  recovery.^  When  pregnant  women 
are  attacked  with  pernicious  anasmia,  abortion  is  to  be  antici- 
pated, with  death  following  not  long  afterwards. 

Treatment. — As  the  fatal  ijemiciousness  of  this  disease  is  only 
absolutely  determined  by  the  result,  it  is  reasonable  always  to 
employ  with  perseverance  those  remedies  and  hygienic  meas- 
ures which  are  most  available  and  effective  for  enrichment  of  im- 
poverished blood,  and  renewal  of  the  blood-making  function. 
As  already  shown,  the  most  important  of  these  are,  the  admin- 
istration of  iron,  arsenic  in  small  doses  (Coupland),  animal  food 
(concentrated  and  liquid  when  digestion  is  weak),  change  of  air, 
and,  if  the  strength  allows  it,  sea-bathing.  Transfusion  of  blood 
has  been  repeatedly  tried  in  cases  of  pernicious  anaemia,  mostly 
in  vain.  Dr.  Austen  Weldon-  asserts  the  cure  of  four  cases  by 
the  intravenous  injection  of  milk.  Dr.  C.  Cary^  obtained  recov- 
ery in  a  case  in  which  iron,  etc.,  had  failed,  by  transfusion  of 
ojaly  fgij  of  human  blood,  by  means  of  Dieulafoy's  aspirator. 

Parasitic  anaemia  has  been  studied  by  observei's  in  different 
parts  of  the  world  ;  e.  g. ,  amongst  laborers  in  the  construction  of 
the  St.  Gothard  tunnel.  There  the  disease  was  traced  to  para- 
sites in  the  intestines.*  Manson,  in  Amoy,  China,  Brisbane  in 
Australia,  and  Wortabel  in  Syria,  have  found  aneemia  of  a  very 
severe  degree  to  be  produced  by  i\\Qfilaria  sanguinis  and  bilharzia 
hiX'tnatohia.^  Sprue^  a  sort  of  anaemic  affection,  with  soreness  of 
the  mouth  and  diarrhoea,  common  in  Java  and  to  some  extent  in 
India,  is  probably  of  a  similar  pathogenetic  nature.  Ko  specific 
treatment  can  be  laid  down  for  such  affections  until  some  mode 
of  safe  elimination  or  desti'uction  of  the  infesting  parasites  can 
be  devised. 

CHLOROSIS. 

Synonyms, — Clihro-anmmia ;  Green  Sickness. 

This  affection  of  girls,  about  the  age  of  puberty,  is  by  some 
regarded  as  simple  anaemia ;  by  others  as  a  pathologically  dis- 
tinct affection.  Symptomatically,  it  is  characterized  by  a  pecu- 
liar waxy,  yellowish,  or  greenish  pallor  of  the  face.  The  lips 
also  are  nearly  colorless,  and  (as  in  common  anaemia)  the  tongue 
is  often  pale.  (Edema  of  the  feet  or  of  the  face  may  occur,  or  a 
dark  circle  may  appear  around  each  eye.  Weakness,  nervous- 
ness, and  palpitations  exist,  with  somewhat  lowered  temperature 

1  J.  H.  Hutchinson,  Med.  News  and  Library,  Philadelphia,  February,  1879. 

2  Med.  Press  and  Circular,  October,  1879. 

3  Buffalo  Med.  and  Sure:.  Journal,  January,  1881. 

*  Meissner,  Schmidt's  Medicinische  Jahrbiicher,  1881. 
6  Phila.  Med.  Times,  June  4,  1881,  p.  .563. 

44* 


522  DIATHESES, 

of  the  body.  A  murmur  (bruit  de  diahle)  is  often  heard  on  aus- 
cultation in  the  region  of  the  heart.  Ringing  in  the  ears,  low- 
ness  of  spirits,  and  disturbed  sleep  are  common.  Digestion  is 
impaired,  and  a  morbid  wppetite  is  sometimes  present,  as  for  coal- 
ashes,  slate-pencils,  chalk,  earth,  or,  in  other  cases,  strong  acids. 
Neuralgia,  affecting  especially  the  abdominal  parietes,  or  myalgia 
may  occur.  Menstruation  is  either  absent  (amenorrhcea),  irreg- 
ular, or  painful  (dysmenorrhcea). 

The  blood  in  chlorosis  has  been  found  deficient  in  corpuscles, 
and  containing  an  excess  of  fibrin.  One  of  the  curiosities  of 
medical  history  is  the  fact  that  crude  theory  led  at  one  time  to 
the  employment  of  venesection  in  its  treatment,  to  diminish  the 
amount  of  fibrin,  whose  excess  was  supposed  to  constitute  it  an 
inflammatory  disease.  Virchow  asserts  the  predisposition  to  it 
to  depend  mostly  upon  some  congenital  abnormity  of  the  heart 
or  the  aorta ;  especially  often  of  the  latter. 

The  duration  of  chlorosis  is  variable.  It  may  be  protracted  for 
years.     It  is  perhaps  never  alone  directly  fatal. 

In  treatment,  measures  adapted  to  anaemia  are  generally  suit- 
able. Good  diet,  sea-bathing,  change  of  air,  light  gymnastics, 
iron,  bitter  tonics,  quinine  (sometimes  even  strychnia  or  nux 
vomica  in  small  doses)  will  all  have  their  place.  Certain  cases 
do  not  bear  iron  well,  from  tendency  to  fulness  of  the  head. 
Some  even,  chlorotic  but  not  anajmic,  need  to  be  relieved  of  that 
symptom  by  the  application  of  a  few  leeches  or  ..cut  cups  to  the 
back  of  the  neck.  It  is  often  best  J;Q<fjM-ecedeW  accompany  the 
administration  of  iron  with  moderate  doses  of  a  laxative  saline 
medicine,  such  as  cream  of  tartar,  or  Hunyadi  Janos,  or  Fried- 
erickshall  mineral  water.  ^ 

Special  attention  to  the  menstrual  function  will  be  demanded. 
Of  this  a  few  words  will  be  said  in  another  place.  (See  Amenor- 
rhoea. ) 

BEKIBEBI. 

This  epidemic  disease  of  Ceylon,  a  part  of  Hindostan,  Japan, 
Northern  Africa,  and  Brazil,  needs  here  to  be  defined.  This  will 
be  done  in  the  words  of  Dr.  Aitken  :'^ 

"A  constitutional  disease,  expressed  in  the  first  instance  by 
anaemia,  culminating  in  acute  oedema,  and  marked  by  stiffness  of 
the  limbs,  numbness,  and  sometimes  paralysis  of  the  lower  extrem- 
ities ;  oppressed  breathing  ;  a  swollen  and  bloated  countenance. 
The  urine  is  secreted  in  diminished  quantity.  The  cedema  is 
general,  not  only  throughout  the  connective  tissue  of  the  muscles, 
but  the  connective  tissue  of  solid  and  visceral  organs  in  every 
cavity  of  the  body  is  bathed  in  fluid.  Effusion  of  serum  into  the 
serous  cavities  very  generally  precedes  death." 

This  disease  may  occur  either  in  the  acute  or  chronic  form. 
Death  may  follow  in  a  few  hours,  or  be  delayed  for  several  weeks. 

1  Of  Hunyadi  Janos  water,  the  dose  is  from  half  a  wineglassful  to  a  wineglassful ;  of 
Friederickshall,  rather  more  is  usually  required  to  operate.  No  active  purgation, 
however,  is  called  for  iu  the  treatment  of  chlorosis.  The  addition  of  chloride  of  ammo- 
nium to  the  tincture  of  chloride  of  iron  makes  it  agree  better  with  some  patients. 
Hayem  and  Reynauld  recommend  the  inhalation  of  oxygen  along  with  the  administra- 
tion of  iron  in  anaemia  and  chlorosis. 

1  Science  and  Practice  of  Medicine,  vol.  ii.,  p.  83. 


MYXEDEMA.  523 

Intemperance  promotes  it.  But  there  must  be  some  undiscov- 
ered elemi^nt  of  local  causation.  Dr.  D.  B.  Simmons,'  of  Yoko- 
hama, asserts  the  occurrence  of  two  forms  of  the  disease  ;  the 
"dry"  and  atrophic,  and  the  "wet,"  accf)mpanied  by  dropsical 
effusion.  Of  these,  the  dry  is  rarely  fatal ;  the  dropsical  is  often  so. 
In  .Japan,  it  attacks  well  nourished  as  well  as  anajmic  subjects  ; 
mostly  between  2U  and  .'JO  years  of  a^e  ;  males  more  frequently 
than  females.  Sedentary  employments  promote  it.  Foreigners 
are  much  less  apt  to  be  aftected  with  it  than  natives  of  Japan. 
Few  cases  occur  except  in  the  warmer  months  of  the  year,  from 
May  to  October.  Dr.  Simmons  believes  its  causation  to  depend 
upon  a  specific  local  ?)iia.s})i,  not  identical  with  the  malarial  cause 
of  autumnal  fevers.  In  treatment,  no  special  antidote  having 
been  discovered,  he  recommends,  in  the  dropsical  cases,  cathartics 
and  diuretics^  with  regulation  of  the  diet.  Rice  is  to  be  avoided, 
and  wheat,  barley,  and  beans  (especially  the  small  red  adzuke  bean) 
should  be  used  for  food. 

Tonics,  stimulants,  and  generous  diet  have  been  generally 
thought  to  be  indicated  in  the  treatment  of  beriberi.  Some  native 
medicines  have  a  reputation  in  India;  but  the  management  of 
the  disease  does  not  appear  to  have  been  satisfactory.  Death  is, 
in  India,  seldom  averted ;  following  either  the  first  attack  or 
relapses. 

MYXCEDEMA. 

Ord  gave  this  name  to  a  "cretinoid  condition"  first  described 
(1874)  by  Sir  "William  Gull,  as  occurring  in  married  women  between 
30  and  50  years  of  age.  Its  characteristic  is  a  general  increase 
and  mucoid  degeneration  of  the  connective  tissue  throughout  the 
body.  "  Ko  hereditary  influence  or  special  exciting  cause  has 
been  given. 

"  The  symptoms  are  characteristic  and  the  disease  can  be  easily 
differentiated.  The  patient  generally  begins  to  swell  and  increase 
in  size,  the  face  has  a  pufiy,  anaemic  look  like  that  of  Bright's 
disease,  but  there  is  no  oedema,  and  rarely  any  albumen  in  the 
urine. 

"  The  movements  become  slow,  the  mind  grows  lethargic,  and 
the  perception  dull;  at  times  the  patient  has  delusions,  or 
becomes  of  sullen  temper ;  the  appetite  is  lessened,  the  bowels 
are  often  constipated. 

"The  temperature  is  very  low,  toward  the  close  of  the  disease 
falling  to  92°,  90°,  88°  F.,  and  in  one  case  even  to  77°  just  before 
death.  The  course  of  the  disease  is  chronic  ;  it  generally  lasts 
ten  or  twelve  3'ears ;  but  the  patient  gradually  becomes  more 
stupid  and  lethargic,  and,  though  there  may  be  an  interval  of 
improvement,  death  seems  to  be  inevitable. 

"No  satisfactory  treatment  has  been  discovered  ;  iron  and  cod- 
liver  oil  have  so  far  been  oftenest  given.  "'^ 

1  Monograph  on  Beriberi,  or  the  Kakke  of  Japan,  Shanghai,  1880. 

2  Med.  Press  and  Circular,  Oct.  15,  1879. 


524  DIATHESES. 


LEUCOCYTH^MIA. 


We  have  defined  this  affection  already.  (See  General  Pathology.) 

The  history  of  its  discovery,  which  has  been  subject  to  contro- 
versy, appears  to  be,  in  brief,  as  follows  :  Velpeau  (1827),  Barth 
and  Donne  (1839)  noticed  in  certain  cases  a  semi-purulent  aspect 
of  the  blood.  Dr.  Craigie,  of  Scotland,  reported  [Edin.  Med.  and 
Surg.  Journal,  vol.  Ixiv.,  1845)  a  case  of  disease  of  the  spleen, 
examined  also  by  Dr.  John  Reid,  in  which  a  peculiar  appearance 
of  the  blood  occurred,  supposed  by  them  to  be  "purulent."  Dr. 
Bennett,  of  Edinburgh,  in  1845,  published  an  account  of  a  similar 
case,  describing  it  as  "suppuration  of  the  blood."  A  month 
later  Yirchow,  of  Berlin,  described  a  case  presenting  the  same 
appearances  under  the  microscope,  as  leukmmia,  or  white  blood, 
asserting  the  view  that  excess  of  the  colorless  corpuscles,  not  sup- 
puration, was  the  true  nature  of  the  affection.  While,  then,  the 
first  facts  were  Dr.  Craigie's,  the  credit  of  discerning  the  path- 
ology which  explains  them  belongs  to  Prof.  Virchow.^  The  first 
diagnosis  of  the  disease  during  life  was  made  by  Dr.  Fuller,  of 
London,  in  1845. 

The  causes  of  leucocythsemia  are  exposure  to  cold  and  wet, 
prostrating  disease,  such  as  typhus,  typhoid,  or  puerperal  fever, 
and  affections  of  the  lymphatic  glands,  or  of  the  spleen,  often  of 
undetermined  origin. 

Its  symptoms  are,  debility,  swelling  of  the  abdomen,  anasarca, 
often  vomiting  or  diarrhoea,  jaundice,  and  hemorrhages  from  the 
nose  or  gums.  The  spleen  and,  sometimes,  the  liver,  are 
enlarged.  The  lymphatic  glands  are  often  so,  also.  The  bones 
(sternum,  ribs,  etc.,)  are  sometimes  tender  to  the  touch.  Cough 
may  occur ;  and  so  may  pustular  eruptions.  The  tendency  of 
the  disease  is  towards  death,  and  it  is  doubtful  whether  any  case, 
well  marked,  has  been  cured.  But  it  is  slow,  and  may  extend 
over  many  years  ;  average  duration,  about  two  years. 

As  to  the  origin  of  leucocythsemia,  writers  'generally  refer  the 
disease  to  three  varieties :  Splenic,  lyr)iph-glandular,  and  myelo- 
genic. The  last  named  indicates  the  supposed  origination  (Neu- 
mann) of  the  superabundant  white  corpuscles  in  the  marrow  of 
the  hones.  It  is  a  hypothesis  of  some  physiologists,  that  bone- 
marrow  is  normally,  in  early  life  at  least,  a  blood-cell  generating 
substance.  Neumann  himself  speaks  doubtfully  on  this  point; 
and  Pouchet,^  after  considerable  investigation,  denies  it  altogether. 
In  any  case,  however,  a  morbid  excess  of  corpuscular  elements 
may  be  contributed  by  any  tissue  which  is  in  part  cellular  ;  and 
there  is  no  doubt  that  marked  tenderness  of  the  bones  exists  in 
some  cases  of  leucocythsemia,  and  that  alteration  in  the  bone- 
marrow  has  in  certain  instances  been  observed  after  death.  It  is 
entirely  possible,  and  even  probable,  that  the  bone-changes  are 
secondary  to,  not  causative  of,  the  leucocythsemia. 

Diagnosis  of  leucocythsemia  is  only  possible  by  microscopic 

1  Prof.  Bennett's  labored  defence  of  his  own  claim  to  priority  does  not,  I  think,  at  all 
contravene  the  above  view.    See  his  "  Clinical  Lectures,  etc.,"  2d  ed.  (N.  Y.),  p.  892. 
a  La  Tribune  Medicale,  March  30,  1879. 


hodckin's   disease.  525 

exiiinhialion  of  the  blood.     A  drop  from  a  needle-prick  of  a  finger 
will  sudice,  placed  under  a  micro- 
scope of  25(3  diameters  or  more.  Fro.  124. 
Instead  of  being  but  one  to  fifty 
or  one  or  two  hundred  of  the  red 
corpuscles,  the    white  blood-cells 
may  l^e  one  to  six  or  four  ;  perhaps 
even  one  to  two  or  three.     (See 
Part    I.,   under    CachexUe;    also, 
Sniieioloyy. )    W hen  a  la rger  quan- 
tity of  blood  is  drawn,  it  has,  after 
heating,  a  whitish  or  milky  look. 
Its  coagulum  is  grayish-white  on           '^^^^'^  ^'^  Leucocythfemia. 
its  surface,    from   excess   of   the 

colorless  corpuscles.  Qnji^Uds  of  a  peculiar  kind  (elongated  octa- 
liedra)  have  been  found  in  the  blood  after  death,  by  Chai'cot, 
Vulpian,  and  others  (iH(iO).  After  death,  coagula  are  found  in 
the  heart,  consisting  of  white  corpuscles  almost  alone. 

We  have  said  that  the  cure  of  leucocytbjemia  has  not  yet  fol- 
lowed any  of  the  many  remedies  tried  for  it.  No  doubt  life  may 
be  prolonged  under  it,  by  hygienic  management,  and  tonics. 
Nitric  and  nitro-muriatic  acid  are  recommended  ;  the  latter  by 
the  bath  as  well  as  internally.  If  the  spleen  be  much  enlarged, 
it  may  be  treated  as  mentioned  under  the  head  of  Diseases  of  the 
iSpleen. 

HODGKIN'S  DISEASE. 

Adenie  is  the  name  given  by  Trousseau  to  an  affection  (called 
by  others  Ilodgkin's  disease,  or  %)seudo-leukoemia)  in  which  the 
spleen  and  lymphatic  glands  are  considerably  enlarged,  with 
reduction  in  number  of  the  red,  without  increase  of  the  white 
blood  corpuscles. 

Though  before  alluded  to  by  several  writers.  Dr.  Hodgkin  gave 
the  first  clear  and  full  account  of  this  affection  (Medico-Ohi- 
rurgical  Transactions,  vol.  xvii.)  in  1832.  Not  uufrequently  most 
or  all  of  the  lymphatic  glands  of  the  body,  cervical,  axillary, 
inguinal  and  deeply  seated,  are  involved  in  enlargement,  with 
fibroid  transformation,  diflerent  from  scrofulosis.  The  caseation 
and  suppuration  of  the  glands,  so  common  in  scrofula,  do  not  appear 
in  it.  No  considerable  disorder  of  the  genei-al  health  occurs, 
except  anaemia,  until  some  of  the  enlarged  glands  cause  disturb- 
ance by  pressure  upon  important  organs,  as  the  trachea,  oesophagus, 
carotid  arteries,  vena  cava,  etc.  The  size  of  the  enlarged  glands 
varies  from  that  of  a  hickory  nut  to  that  of  a  hen's  egg.  Groups 
of  glands  together  may  attain  to  a  much  more  considerable  mag- 
nitude. 

The  duration  of  this  disease  averages  less  than  two  years. 
Ana!mia  and  debility  increase,  general  dropsy  is  apt  to  come  on, 
and  the  interruption  of  various  functions  at  last  exhausts  the 
system. 

Treatment. — Kemoval  of  the  enlarged  glands  has  often  been 
practised.  In  a  few  cases  only  ( Verneuili  does  this  seem  to  have 
had  any  efiect  in  arresting  the  disease.    The  most  favorable  cases 


526  DIATHESES. 

for  such  treatment  are  those  in  which  the  glandular  growth  is 
confined  to  a  single  region  of  the  body;  without  enlargement  of 
the  spleen,  or  marked  general  debility.  Fever,  when  present, 
should  forbid  operative  interference  ;  and  so  should  anaemia ; 
especially  when  that  is  ascertained  by  microscopic  examination 
of  the  blood.  Excision  of  glands  in  certain  parts  of  the  body 
for  the  relief  of  pressing  symptoms,  may  be  sometimes  appro- 
priate, 

No  special  medicinal  ti-eatment  has  been  found  to  control  or 
essentially  modify  the  diathesis  of  lymphadenosis.  Iron  and  cod- 
liver  oil  may  be  rationally  administered,  on  account  of  the  anae- 
mia always  present ;  but  iodine,  arsenic,  and  many  other  alter- 
atives have  been  largely  tried,  and  have  usually  failed  to  do 
any  considerable  good.  Warfyinge,^  however,  reports  beneficial 
effects  from  arsenic,  in  four  cases. 

"Absorption  of  pus,"  as  such,  through  the  walls  of  the  blood- 
vessels, being  shown  to  be  improbable  on  account  of  its  cellular 
nature,  the  pus-cells,  moreover,  being  too  large  to  pass  through 
the  finer  capillaries,  other  views  are  now  advanced.  This  improba- 
bility of  cell-migration  has  been,  of  course,  rendered  less,  tjy  the 
investigations  of  Cohnheim  upon  the  results  of  inflammation. 
Yet  the  escape  of  leucocytes  from  blood-vessels,  under  pressure, 
must  be  supposed  to  occur  much  more  readily  than  the  reverse 
process,  of  absorption  of  pus-cells  into  the  vessels.  Under  the 
name  pysemia,  indeed,  several  affections  are  often  included.  1. 
Septicoemia (Guerin)  or  ichorhcemia;  i.  e.,  blood-contamination  from 
the  absorption,  in  a  liquid  state,  of  putrescent  or  otherwise  mor- 
bific material ;  2,  Transfer  by  veins  of  actual  pus,  in  cases  of 
phlebitis  (Lee),  and  its  deposit  in  new  localities  ;  3,  Tliromhosis 
(Yirchow),  or  coagulation  in  a  vein  during  life,  followed  by 
embolism,  or  the  conveyance  of  a  portion  or  portions  of  coagulum 
to  different  parts,  causing  irritation,  or  obstruction. 

That  inflammation  of  a  vein  (phlebitis)  does  not  very  unfre- 
quently  occur,  there  is  no  doubt.  But  the  external  coat  and 
surrounding  connective  tissue  are  generally  most  involved  ;  and 
suppuration  of  its  internal  lining  is  rare.  Coagulation  is  much 
more  frequent.  Embolism,  however,  as  well  as  thrombosis  may, 
and  often  does,  take  place,  without  any  of  those  general  symptoms 
to  which  the  name  of  "  purulent  infection  "  is  given.  Most  prop- 
erly, 1  consider,  the  name  pyaemia  should  be  restricted  to  cases 
in  which,  to  cite  the  words  of  J.  Simon,  "some  diseased  part 
(which  need  not  be  an  external  wound)  so  affects  the  blood  circu- 
lating through  it,  that  this  blood  afterwards  excites  destructive 
suppuration  in  parts  to  which  the  circulation  carries  it — namely, 
commonly  first  in  the  lungs,  or  (in  certain  cases)  liver  and  lungs, 
and  later  generally  about  the  body.  Putrid  infection,  septicaemia 
or  ichorhaemia,  may  occur  without  local  suppuration,  but  with 
symptoms  otherwise  similiar.     Clinical  convenience  may  for  the 

1  London  Med.  Record,  March  15, 1881. 
8  First  named  pyohwmia,  by  Piorry. 


PViEMIA.  527 

present  readily  excuse  the  common  designation  of  all  such  cases 
by  tlie  term  i)y<iemia." 

Klebs,  Tiegel,  and  others,  in  their  experimental  researches, 
have  identified  pya?mia  with  septicfcmia.  Birch-IIirschfeld' 
asserts  an  important  distinction,  in  tlie  presence  of  micrococci  in 
the  pus,  and  in  the  blood,  of  the  former  affection,  but  not  in  the 
latter.  Vogt  found  abundance  of  monads  in  a  pyaemic  abscess. 
Recklinghausen  has  asserted  the  dependence  of  "  multiple  metas- 
tatic abscesses  "  upon  extra-vascular  accretions  of  fungi. 

Prescott  Ilewett^  has  reported  twent3'-three  cases  of  pyaemia 
in  private  practice^  seven  of  which  occurred  in  the  country,  and 
all  under  favorable  sanitary  conditions.  In  six  of  these  cases 
some  surgical  operation  had  been  performed  ;  in  eleven  there  was 
a  broken  surface  ;  in  six,  not  even  an  abrasion.  It  appears  from 
such  facts  that  a  constitutional  predisposition  to  pyaemia  must 
exist  in  certain  individuals  ;  and  that  some,  at  least,  of  the  causes 
of  this  affection  are  "still  to  be  worked  out." 

Symptoms  of  such  an  affection  are,  chills,  low  fever,  rapidity 
and  feebleness  of  the  pulse,  vomiting,  delirium  and  swelling  of 
the  joints.  Death  may  occur  in  a  few  days  from  devitalization 
of  the  blood  ;  or,  if  purulent  formations  occur,  by  exhaustion 
caused  by  their  presence  and  discharge. 

In  the  treatment  of  pyaemia  or  septicaemia,  support  and  depu- 
ration of  the  blood  are  the  indications.  Pure  air  is  not  only  pre- 
ventive, but  positively  curative  of  such  affections.  Of  medicines, 
the  attention  of  the  profession  has  been  especially  called  to  the 
sulphites  and  hyposulphites  of  sodium,  calcium,  and  magnesium, 
carbolic  acid,  and  salicylic  acid  as  antiseptic  remedies.  Tbey 
are  under  trial.  Several  favorable  cases  of  their  use  are  reported  ; 
although  in  the  U.  S.  army,  during  the  late  war,  disappointment 
was  experienced  by  a  number  of  those  who  employed  the  sul- 
phites. Sulphite  of  sodium  may  be  given  safely  to  the  extent 
of  four  or  five  drachms  daily  ;  the  bisulphite  (Wood),  about  half 
as  much,  or  less.  It  is  certainly  proper  to  give  these  remedies 
a  full  and  prolonged  trial. 

Dr.  Fordyce  Barker^  emphatically  urges  the  power  of  quinine 
to  control  the  tendency  to  suppuration,  and  to  prevent  pyaemia 
and  septicaemia.  He  gives  it,  for  this  purpose,  in  10  to  15  grain 
doses,  morning  and  evening,  until  constitutional  effects  are  pro- 
duced. It  is  not  easy  to  see  why  quantities  somewhat  smaller 
(say  15  grains  daily)  might  not  be  equally  relied  upon.  Dr.  J.  S. 
Holden  {Lancet,  January  31,  1874)  reports  the  recovery  of  a 
severe  case  of  pyaemia  under  the  use  of  half-drachm  doses  of  oil 
of  turpentine. 

Good  nursing  is  indispensable  in  pyaemia ;  and  concentrated 
liquid  food  is  of  great  consequence.  Dr.  Joseph  Bell  [Edin.  Med. 
Journcd,  Jan.,  1870)  reports  three  recoveries,  in  which,  with  hardly 
any  medicine,  he  gave  milk  with  lime-water,  eggs,  and  beef-tea 
at  short  intervals.  Dr.  .John  Wood  ^  advises  saturating  the  air 
around   the   patient  with  carbolic   acid   by  hanging   materials 

1  Gaz.  MSdicale  de  Paris,  No.  20  el.  seq.,  1873. 

2 Brit.  Jletl.  Journal,  Jamiarv  31,  1S7-1. 

3N.  Y.  Medical  Record,  July  15,  1S73.  i Practitioner,  Jan.,  1871. 


528 


DIATHESES. 


containing  it  near  his  bed.  We  can  only  suppose  this  to  be 
required  when  he  is  necessarily  confined  to  a  room  in  which  the 
atmosphere  is  not  fresh  and  pure.  Abundant  ventilation  will  be 
much  better. 

THROMBOSIS  AND  EMBOLISM. 

Cruveilhier,  many  years  ago,  proved  that  in  inflamed  veins  a 
clot  is  formed,  principally  fibrinous.  GruUiver  ascertained  that  a 
granular  degeneration  of  the  central  layers  of 
such  a  coagulum  may  occur,  giving  a  "  puri- 
form"  character  to  their  substance.  Yir- 
chow  then  demonstrated  that  portions  of 
such  clots  may  be  carried  from  their  first 
seat  in  the  circulation,  and  form  plugs  in 
the  pulmonary  or  some  other  artery.  After- 
wards it  was  shown  (Paget,  Druitt,  Kirkes, 
Goodfellow,  etc.)  that  not  only  thromhosis  in 
veins,  with  or  without  inflammation,  but 
also  inflammatory  or  degenerative  deposits 
on  the  heart's  valves,  may  give  off  emboli  or 
floating  masses,  which  may  obstruct  the  ar- 
teries of  the  lungs,  liver,  brain,  or  other  or- 
gans, causing  atrophy,  or  irritation  and  in- 
flammation. The  septic  degeneration  of  the 
debris  of  such  clots  may  also  contaminate 
the  blood — causing  septicaemia  or  ichorhse- 
mia.  Fatty  embolism  may  thus  result 
(Eberth^).  Fatty  emboli  are,  moreover, 
sometimes  (E.  Wagner,  Bergmann^)  traced 
to  fractures  or  other  injuries  involving  the  medullary  canals  of 
bones.  Zenker  has  reported  a  case  of  fungous  embolism,  occur- 
ring with  thrush  ;  mycelium  of  the  oidium  albicans  penetrating  the 
mucous  membrane  and  being  conveyed  by  its  small  vessels  to  the 
brain,  producing  there  numerous  small  abscesses. 

In  300  fatal  cases  of  endocarditis  at  Berlin,  Sperling  found 
embolism  to  have  occurred  in  29  per  cent. ;  in  26  of  which  cases 
it  was  upon  the  left  side.  When  upon  the  right  side,  it  was 
always  in  the  lungs.  Spalding  observed  the  kidneys  to  be 
affected  with  embolism  in  the  greatest  number  of  cases ;  next, 
the  spleen ;  afterwards,  the  brain  and  other  parts.  In  practice, 
the  symptoms  of  cerebral  embolism  have  especially  brought  it  be- 
fore the  notice  of  pathologists. 

Multiple  embolism  is  the  term  applied  when,  as  a  consequence 
of  ulcerative  endocarditis,  many  small  fragments  of  plastic  exuda- 
tion upon  the  heart-valves  pass  into  the  circulation  and  obstruct 
the  smaller  arteries  of  various  organs.  The  kidneys,  spleen,  and 
liver  are  especially  apt  to  be  thus  affected. 

Emboli  are,  apart  from  their  origin,  chiefly  arterial  or  venous  in 
their  locality  of  arrest.  Capillary  embolism  is  noticed  especially 
in  the  brain.    The  arteries  most  often  obstructed  are,  those  at  the 

iMed.  Times  and  Gazette,  Oct.  11,  1873.    Osmic  acid  detects  fatty  embolism,  by  color- 
ing fatty  matter,  and  not  the  normal  ingredients  of  the  blood. 
2  Berliner  Klinische  Wochenschrift,  Aug.  18,  1873. 


Thrombus  in  Saphe- 
nous Vein. 


THROMBOSIS    AND    P^MBOLISM, 


i29 


Fig.  126. 


base  of  the  brain,  the  internal  carotid,  the  femoral,  brachial, 
splenic,  rcual,  external  carotid,  and  mesenteric  arteries.  One 
obstruction  is  apt  to  be  the  source  of  others.  Cessation  of  the 
pulse  of  the  arteries  in  a  limb  is  an  early  positive  sign.  Gangrene 
is  usually  the  last  and  fatal  event,  if  an  extremity  be  involved. 

When  tlie  right  half  of  the  heart  has  received  an  embolus,  and 
the  pulmonary  artery  is  obstructed,  collapse  of  the  lungs,  partial 
or  entire,  follows.  Pleurisy,  hemorrhage,  or  bronchitis  may 
occur  also.  Or  the  symptoms  may  be,  great  anxiety  and  dysp-,_ 
noea,  with  reduction  of  the  temperature  of  the  body.  A  systolic 
murmur  may  be  heard  on  auscultation ;  the  rhythm  of  the  heart 
becomes  irregular;  and  pulsation  of  the  jugular  veins  may  be 
noticed.  Giddiness  may  be  present,  with  blueness  and  oedema 
of  the  hands,  or  feet,  or  both.  Death  occurs  in  much  the  greater 
number  of  cases  of  embolism. 

Ante-mortem  dots  in  the  heart  (denied  by  some)  undoubtedly 
occur  in  a  few  instances.  Dr.  B.  W.  Richardson  gives  as  the 
characters  of  such  a  clot :  1st,  its  filling  a  cavity ;  2d,  its  being 
grooved  externally  by  a  current  of  blood,  or  bored  by  a  current 
through  its  centre;  3d,  its  being  firmly  adher- 
ent to  the  walls  of  the  heart ;  4th,  its  being 
deeply  indented  by  the  surrounding  structures. 
Such  clots  are  said  to  be  met  with  in  cases  of 
croup,  diphtheria,  pneumonia,  peritonitis,  the 
ovarian  operation,  child-birth,  erysipelas,  scar- 
let fever,  and  some  obscure  cases  almost  with- 
out symptoms  till  near  the  time  of  death.  Dr. 
Richardson  thinksHhat  the  free  administration 
of  anmionia  (with  iodide  of  potassium)  may  save 
life  in  some  such  cases. 

Symptoms. — Where  emboli  have  become 
broken  up  and  decomposed,  septicaemia  results 
—commonly  known  as  pyaemia,  as  before  ex- 
plained. The  temperature  in  this  disorder  is 
commonly  high ;  from  100°  to  107°  in  the  evening 
exacerbation.  Dr.  LiddelP  asserts  thrombosis  of 
the  minute  arteries  of  the  brain  to  be  not  uncommon  in  aged  or  en- 
feebled persons.  Occasionally  it  may  originate  hi  erysipelas,  or 
some  other  inflammatory  attack ;  or  it  may  be  traumatic  ;  or  depend- 
ent upon  constitutional  syphilis,  or  on  intemperance.  Oftener,  it  is 
marasmic;  i.  c,  attendant  upon  a  general  decline  of  organic 
force,  with  weakness  of  the  heart  and  increased  coagulability  of 
the  blood.  Dizziness,  frontal  headache,  dilatation  of  pupils,  tin- 
nitus aurium,  and  tendency  to  lethargy,  are  early  symptoms  of 
such  a  state  of  things ;  later  comes  paralysis,  especially  hemi- 
plegia, and  often  convulsions.  Cerebral  embolism  occurs  more 
suddenly  than  thrombosis,  and  frequently  in  .younger  subjects. 
There  is,  also,  generally,  in  embolism,  evidence  of  disease  of  the 
heart,  or  of  some  other  organ,  preceding  and  accounting  for  the 
attack.   Several  slight  attacks  of  paralysis  are  apt  to  accompany 


Embolus  of  Pulmo- 
nary Artery. 


45 


1  British  Med.  Journal,  Dec.  14,  1872. 

2  Am.  Jouraal  of  Med.  Sciences,  April,  1873. 

21 


530  DIATHESES. 

thrombosis ;  one  severe  paralytic  attack,  embolism.  Between 
cerebral  embolism  and  acute  meningitis,  or  phrenitis,  Broca  has 
pointed  out  the  distinction  that  the  temperature  of  the  head  is 
commonly  lowered  in  the  former,  but  elevated  in  inflammation  of 
the  brain. 

For  treatment  of  embolism  without  septicaemia,  our  only 
resources  are  rest,  support  by  food  and  stimulants,  and  alleviation 
of  nervous  disturbance  by  opiates. 

MUCOUS  DISEASE. 

Eustace  Smith '  and  others  have  given  this  name  to  an  affection, 
most  common  in  women  from  thirty  to  forty  years  of  age,  in  which 
an  excessive  secretion  of  unhealthy  mucus  occurs,  chiefly  in  the 
bowels,  with  more  or  less  consolidation  in  shreds  or  tubular  casts, 
accompanied  by  symptoms  of  indigestion,  palpitation  of  the  heart, 
and  mental  depression.  The  mucus  may  be  discharged  at  variable 
intervals,  in  membranous  or  concrete  masses.  Under  the  micro- 
scope these  are  found  to  consist  (Whitehead^)  of  layers  of  an 
amorphous  matrix,  with  epithelial  and  spherical  cells  imbedded, 
as  well  as  free  nuclei,  triple  phosphate,  etc.  In  treatment,  the 
indications  are,  constitutional  invigoration,  removal  of  the  mucus 
by  alkaline  injections,  and  the  use  of  mild  astringents  to  prevent 
its  reformation. 

ANGEIOLEUCITIS. 

Definition. — Inflammation  of  a  lymphatic  vessel. 

Causation. — Any  local  irritation  or  injury  may  cause  a  neigh- 
boring lymphatic  to  inflame ;  but  it  is  especially  apt  to  follow  a 
poisoned  wound.  Erysipelas  may  be  attended  by  it.  Dissecting 
wounds  almost  invariably  produce  it.  In  my  own  person  this  has 
happened  several  times;  once,  the  absorbed  matter  so  affected  the 
whole  trunk  of  the  lymphatics  proceeding  from  the  right  thumb, 
as  to  cause  a  large  abscess  in  the  axilla,  with  a  severe  illness. 
This  experience  has  enabled  me  to  arrive  at  a  somewhat  clear 
conclusion  as  to  the  nature  and,  consequently,  proper  treatment 
of  "dissecting  wounds,"  which,  from  want  of  care  in  the  pre- 
vention (by  sucking  and  washing  the  part  thoroughly  at  the 
moment  of  the  injury),  have  been  allowed  to  bring  on  local  and 
lymphatic  inflammation. 

The  pathognomonic  sign  of  angeioleucitis  is  a  distinct  and 
somewhat  elevated  red  line  up  the  limb  or  the  part,  with  tender- 
ness well  marked  throughout  its  course. 

That  produced  by  a  dissecting  wound  is,  as  I  have  proved  in 
my  own  case,  an  inflammation,  which  may  be  quite  sthenic;  not 
necessarily  "typhoid,"  as  some  have  imagined.  I  am  sure  that 
the  free  application  of  leeches  to  the  hand,  and  a  large  dose  of 
Epsom  salts,  aborted  one  attack,  which  was  threatening  to  be 
severe.  Of  course,  some  cases  may  be  asthenic  or  typhoid;  but 
of  all  that  I  have  seen,  with  three  examples  in  my  own  person, 
none  have  been  so. 

1  On  Wasting  Diseases  of  Infants  and  Children,  London,  1870. 

2  Manchester  Medical  and  Surgical  Reports,  1870. 


ONYXIS,  531 

In  ordinary  an.freiolcucitfs  the  application  of  a  light  muslin  or 
linen  rag,  wot  with  lead-water  and  laudanum,  allowed  to  evapo- 
rate, will  be  suitable.  The  part  must,  also,  of  course,  be  kept 
entirely  at  rest. 

WHITLOW. 

Synonym, — Fchn^  The  frequency  with  which  this  comes 
under  every  physician's  notice  makes  it  a  proper  topic  for  brief 
remark  here.  A  felon  or  whitlow  is  a  suppurating  inflammation 
of  one  or  more  of  the  fingers.  Velpeau's  subdivision  of  its 
varieties  is  as  good  as  any ;  into :  1.  Sub-epidermic.  2.  Sub- 
cutaneous. 3.  Fibro-synovial.  4.  Periosteal.  The  first  is 
trifling ;  the  second  may  be  severe  for  several  days ;  the  third 
may  cause  great  suffering  for  two  or  three  weeks  and  lame  the 
hand  ;  the  fourth  threatens  the  loss  of  a  phalanx  or  of  the  finger. 

Many  practitioners  alwa3^s  divide  an  inflamed  finger  down  to 
the  bone  as  soon  as  it  is  manifest  that  the  inflammation  is  sure 
to  progress.  Velpeau  advised  early  incision  only  in  that  form 
in  which  periostitis  exists.  I  believe  he  was  right.  The  only 
difficulty  is  in  making  sure  of  the  diagnosis.  But  I  would,  upon 
experience,  lean  towards  the  doubt,  and  wait  for  suppuration, 
unless  satisfied  of  the  deep-seated  nature  of  the  attack. 

Leeching,  plunging  the  finger  in  spirits  of  camphor,  water- 
dressing  or  irrigation,  and  poultices,  comprise  the  rest  of  the 
treatment. 

ONYCHIA. 

Synonym. — Paronychia.  Inflammation,  followed  by  suppura- 
tion or  ulceration  about  the  root  of  the  nail.  Injuries  generally 
bring  it  on,  but  cachectic  constitutions  are  most  liable  to  it.  The 
nail  may  become  loosened  so  as  to  be  removable.  Much  more 
rarely,  the  last  phalanx  of  the  finger  or  toe  suffers  necrosis. 
Poultices,  lime-water,  solution  of  sulphite  of  sodium,  etc.,  with 
rest  to  the  part,  in  bed  if  it  be  a  toe,  comprise  the  usual  means 
of  treatment. 

ONYXIS. 

This  is  commonly,  but  improperly,  called  in-groiving  nail.  The 
great  toe  is  its  much  most  frequent  seat.  It  is  an  inflammation 
of  the  soft  parts  near  the  nail ;  their  swelling  pressing  upon  the 
latter  ;  not  the  nail  growing  toward  or  into  the  flesh.  The  difter- 
ence  is  important  in  reference  to  the  treatment.  Por  this,  the 
patient  must  remain  in  bed,  or  at  least  avoid  walking,  until  the 
inflammation  of  the  toe  sul^sides.  Then  the  ulceration  may  be 
treated,  if  extensive,  with  lime-water,  solution  of  sulphate  of 
copper,  persulphate  of  iron,  etc.  ;  and,  if  fungous  pi-otrusion  of 
indolent  granulations  (proud  flesh)  exists,  with  touches  of  solid 
nitrate  of  silver  every  day  or  two.  After  this,  or  in  milder  cases 
from  the  first,  a  little  strip  of  lint  or  cotton  smeared  witli  simple 
cerate,  or  a  thin  strip  of  India-rubber  (Ozanam),  or  a  thin  plate 
of  silver  (Finch),  should  be  carefully  worked  with  the  back  of  a 
small  knife-blade,  or  the  head  of  a  large  needle,  in  between  the 
flesh  and  the  nail,  to  be  left  there.     Adhesive  plaster  may  be  put 

1  The  te.xm  paronychia  is  best  restricted  to  cases  occurring  near  the  nail. 


532  DIATHESES. 

on,  so  as  to  draw  the  flesh  away  from  the  nail,  which  is  first 
trimmed  closely  and  smoothly  at  its  edge.  Then  2)Ci'int  the  parts 
thickly  with  collodion.  This  makes  an  artificial  cuticle  ;  the  cure 
will  generally  be  rapid  and  complete,  unless  in  malignant  disease 
of  the  matrix  of  the  nail  itself.  I  do  not  think  that  the  nail 
need  ever  be  removed  for  simple  onyxis.  I  have  certainly  known 
many  cases  to  recover  without  that  operation.  In  onychia  maligna^ 
MacCormac's  treatment,  by  dusting  the  part  with  powdered  ni- 
trate of  lead,  has  met  with  much  favor. 

Corns  (clavus)  require,  in  treatment,  to  be  relieved  of  direct 
pressure.  If  inflamed,  poultices,  cold  cream,  or  lime-water  and 
oil  may  be  required  to  remove  irritation  and  tenderness.  Then 
the  callous  portion  should  be  carefully  pared  away.  Cut  a  hole 
of  the  size  of  the  corn  in  a  round  piece  of  adhesive  plaster ;  place 
this  over  the  corn,  and,  upon  it,  one  or  two  thicknesses  more  of 
the  same  plaster.  This  will  usually  protect  it  so  that  a  shoe  can 
be  worn.  Another  method  of  treatment  is  to  drop  upon  the  corn 
every  night  a  drop  of  pure  tincture  of  chloride  of  iron. 

CARBUNCLE. 

Sjmonym. — Anthrax.  Though  approaching  or  passing  the 
bounds  of  surgery,  the  same  reasons  will  excuse  a  word  about 
this  affection  also.  The  causes  of  it,  as  well  as  of  furunculus  or 
boil,  are  undetermined.  Boils  and  carbuncles  are  positive  oppro- 
hia  medicine;  no  one  knows  how  to  prevent  them  or  to  stop  their 
continued  recurrence.  I  have  known  ten  or  twenty  boils  or  car- 
buncles to  follow  each  other,  in  spite  of  purgatives,  low  diet, 
strong  diet,  tonics,  refrigerants,  alteratives,  and  even  the  sul- 
phites, all  tried  in  turn.  Bullar  and  Watson  report  excellent 
effects  from  the  use  of  dilute  sulphuric  acid,  in  arresting  a  ten- 
dency to  these  affections.  S.  Ringer  eulogizes,  for  the  same  pur- 
pose, the  sulphites  of  sodium,  potassium,  and  calcium.  Dr. 
Simon,  of  Lorraine,  strongly  commends  the  local  application  of 
spirits  of  caynphor,  as  soon  as  a  boil  or  carbuncle  is  threatened. 
The  addition  of  one-fourth  as  much  carbolic  acid  will  probably 
render  this  remedy  more  effectual.^  Dr.  Planaf^  asserts  that  he 
Las  found  arnica  to  have  a  special  effect  in  aborting  boils.  He 
applies  to  them  an  unguent,  of  one  part  of  extract  of  fresh  arnica 
flowers  to  two  parts  of  honey,  spread  on  lead  plaster  or  oiled 
silk.  Dr.  Sidney  Ringer  and  Dr.  P.  N.  Otis-'  assert  that  the 
internal  use  of  sulphide  of  calcium  (gr.  ^  every  two  hours  through 
the  day)  has  a  decided  effect  in  arresting  processes  of  suppura- 
tion, phlegmonous  or  furuncular. 

Carbuncle  is  a  subcutaneous  phlegmonous  inflammation,  more 
extensive  than  a  boil,  and  attended  by  a  larger  sloughing  of  con- 
nective tissue  under  the  skin,  with  much  more  pain  and  constitu- 
tional disturbance.  It  may  even  threaten  life,  especially  when  it 
occurs  on  the  face.     The  swelling  is  round,  and  flattened  on  its 


1  Dr.  H.  G.  Landis,  of  Ohio  {Philada.  Med.  Times,  March  8,  1873),  asserts,  on  the  basis 
of  observation,  a  temporary  excess  of  leucocytes  in  the  blood  in  those  suffering  from 
boils;  suppuration  relieving  this  excess. 

2  Journal  de  Therapeutique,  Jan.  25,  1878. 
«  N.  Y.  Med.  Journal,  May,  1880. 


Addison's  disease.  533 

elevated    surface.     Redness    may   exist    for   some    distance  Ije- 
yond  it. 

la  tlu^  treatment  of  car])uaclc,  besides  emollient  poultices  or 
warm-water  dressing  under  oiled  silk,  almost  all  surgeons  agree 
that,  at  an  early  period,  the  tense  skin  must  be  divided  or  removed, 
to  allow  the  extrusion  of  the  slough  and  detained  pus.  Many 
make  a  crucial  incision,  quite  across  the  tumor  each  way.  Velpeau 
preferred  a  radiated  incision  ;  from  the  centre  in  several  directions, 
extending  a  little  beyond  the  circumference  of  the  tumor.  Bryant 
and  others  have  deprecated  this  practice  of  extended  incisions. 
Probably  no  method  is  better  than  to  congeal  the  part  with 
Richardson's  or  some  other  spray-producer,  with  rhigolene  or 
ether,  and  appl}'^  caustic  potassa  freely,  until  the  whole  top  of  the 
carbuncle  is  deeplj'  blackened.  Poultices,  etc.,  will  of  course  1)6 
afterwards  required.  Zimberlin'  has  found  congelation  with 
ether-spray  to  succeed  in  ctfecting  cures,  without  any  other  local 
treatment.  Paget-  reports  only  4  deaths  in  about  200  cases  of 
carbuncle,  treated  without  incisions,  upon  general  principles,  with 
poultices,  good,  but  not  too  stimulating  diet,  quinine,  opium,  and 
pure  air.  He  objects  to  the  large  use  of  stimulants  in  this  aflfection, 
as  well  as  to  confinement  in  close  rooms.  O'Ferrall's  treatment  by 
concentric  pressure  with  adhesive  straps  has  now  the  advocacy  of 
some  good  surgeons.-'  Dr.  J.  C.  Nott*  has  procured  cures  by  paint- 
ing the  carbuncle  with  pure  carbolic  acid.  Generally  the  patient 
requires  to  l)e  supported  by  good  diet,  and  perhaps  tonics.  Chlo- 
rate of  potassium  is  highly  recommended  by  some  practitioners. 

ADDISON'S   DISEASE. 

Synonym. — Melasma  Supra-renalis.  Hardly  any  clinical  asso- 
ciation of  morbid  changes  is  more  obscure  in  its  pathology  than 
this.  It  occurs  mostly  in  young  adults,  and  twice  as  often  in 
males  as  in  females.  A  bronze-like  discoloration  of  the  skin  conies 
on  gradually,  preceded  and  accompanied  by  symptoms  of  ansemia 
and  debility  (muscular  weakness,  feebleness  of  the  heart's  impulse 
and  pulse  at  the  wrist,  short  breath  upon  exercise,  impaired  diges- 
tion, vomiting,  sometimes  dimness  of  vision) ;  after  lasting  from 
less  than  one  year  to  four  or  five  years,  death  occurs  by  asthenia, 
and  the  only  characteristic  lesions  are  found  to  affect  the  supra- 
renal capsules.  Dr.  Wilks  has  been  almost  as  prominent  as  the 
late  Dr.  Addison  (1854)  in  the  study  of  this  disease.  Dr.  Green- 
how  has  written  an  excellent  monograph  (Lectures)  upon  it.  Dr. 
W.  Pepper  has  suggested  the  idea  of  a  close  relation  between 
this  affection  and  progressive  pernicious  aupemia. 

It  is  manifestly  a  cachexia.  Probably  both  the  supra-renal 
capsular  disease  and  the  affection  of  the  skin  (olive-greenish 
darkening,  nuilatto-like,  or  like  bronze  without  the  gloss)  depend 
upon  the  constitutional  state.  Perliaps  caries  of  the  vertebrae 
(scrofulous)^  which  has  been  sometimes  observed,  may,  by  involv- 

1  Schmidt's  Jahrb.,  No.  1,  1881. 

2  Lancet,  Jan.  IG,  1869. 

»  Am.  .Tournal  of  Med.  Sciences,  July,  1870,  p.  277. 
<  New  York  Medical  Journal,  January,  1871. 

45* 


534 


DIATHESES. 


ing  the  ganglia  in  disease,  thus  produce  the  complex  errors  of 
nutrition,  superficial  and  general.  Dr.  Wilks  describes  the  appear- 
ances of  the  supra-renal  capsule  as  resembling  those  of  scrofulous 
l3'-mphatic  glands  ;  a  lardaceous  material  being  deposited,  which 
afterwards  softens  into  a  putty-like  mass  (grayish  translucent 
material  with  yellow  cheesy  nodules),  or  undergoes  drying  into  a 
chalky  concretion.  Dr.  Austin  Plint^  considers  it  probable  that 
degenerative  disease  of  the  gastric  and  intestinal  tubules  is  the 
cause  of  the  ansemia  so  prominent  in  this  affection.  Dr.  M. 
LetuUe  (La  France  Med.,  1880,  ISo.  40)  has  pointed  out  its  occa- 
sional association  with  tuberculous  disease  of  the  spinal  column. 
Wilks  and  Moxon  have  found  tuberculization  of  the  lungs  in  12 
out  of  15  cases.  The  disease  is  fatal  always,  at  last.  Its  average 
duration  is  about  15  months.  The  termination  is  usually  gradual, 
though  sometimes  by  diarrhoea,  convulsions,  or  coma.  Besides 
hygienic  management,  and  perhaps  iron  or  other  tonics,  little 
treatment  is  recommended  for  it.  Dr.  Greenhow  asserts  decided 
advantage  to  have  followed  the  use  of  a  combination  of  glycerin, 
in  two-drachm  doses,  with  fifteen  or  twenty  minims  each  of  spirit 
of  chloroform  and  tincture  of  chloride  of  iron. 


GOITRE. 

Synonjrm. — Broncliocele.   In  low  and  narrow  valleys  of  the  Alps, 
Andes,  Himalayas,  or  other  mountains,  but  especially  often  in 

Switzerland,   whole   families   and 
Fig.  127.  village    populations    are    affected 

with  (congenital  or  early)  enlarge- 
ment of  the  thyroid  glands,  which 
sometimes  becomes  enormous.  A 
stranger,  after  residence  for  a 
few  months  in  one  of  the  same 
localities,  may  be  likewise  affected; 
and  then  leaving  it  for  a  high  and 
open  salubrious  country,  may  re- 
cover from  it.  Associated  often, 
but  not  always,  with  this  affection 
of  the  neck,  is  cretinism  ;  a  con- 
dition of  bodily  and  mental  weak- 
ness, stunting,  and  deformity,  most 
lamentable. 

Occasionally,  in  any  locality,  a 
case  of  goitre  or  enlargement  of 
the  thyroid  gland  to  a  slight  or 
moderate  degree  maybe  met  with. 
I  do  not  remember  having  seen 
Bronchocele.  more   than  twenty  cases   of  it  in 

Philadelphia ;  none  of  them  severe. 
Michaud  (Gazette  Medicale,  Jan.  10  and  Feb.  7,  1874)  states  that 
goitre  has  been  several  times  epidemic  in  the  French  army,  while 
the  men  were  making  forced  marches  with  insufficient  diet  in  a 
mountainous  country. 


1  N.  Y.  Me4.  Journal,  March,  1871. 


GOITRE.  535 

Varieties  of  thyroid  enlargement  are,  the  soft,  fibrous,  and 
aneiiris)nal  goitre.  The  first  of  these  may  acquire  the  characters 
of  a  cyst  or  cysts.  The  second  is  slow  in  growth,  and  trouhle- 
some  only  Avhen  large,  from  pressure.  Suppuration  of  it  has 
occurred  in  very  rare  cases.  Enlargement  behind  the  pharynx 
(reti-o-phax-yngeal  goitre)  has  sometimes  given  troul)le.  Aneuris- 
mal  goitre  (with  dilatation  of  some  or  all  of  the  blood-vessels  of 
the  gland)  is  the  least  common,  but  the  most  liable  to  serious  acci- 
dents, as  hemorrhages,  etc. 

Death  resulting  immediately  from  goitre  is  rare.  An  instance 
of  it  occurred  in  1879,  in  the  New  York  Hospital;  asphyxia 
being  produced  (in  a  middle-aged  woman)  by  pressure  of  the 
tumor  upon  the  trachea.^  Eose-  has  shown  that  sometimes  the 
gi'adual  influence  of  pressure  causes  fatty  degenei-ation  of  some 
of  the  rings  of  the  trachea,  making  it  flaccid  and  yielding  to  any 
sudden  movement  of  compression. 

The  occasional  association  of  goitre,  in  an  acute  form,  with 
menstruation,  or  with  pregnancy,  has  been  noticed  by  several 
writers  (Petit,  1740,  Gaillot,  Ollivier,  Lawson  Tait). 

[For  Exo^jlithalviic  Goitre,  see  ante,  under  Diseases  of  Organs  of 
Circidation.] 

Causes  of  goitre,  among  the  mountains,  are  believed  to  be,  1. 
Excess  of  mineral  matter,  especially  magnesia,  iron,  copper,  lead, 
baryta,  and  lime,  in  the  drinking-water  ;•*  2.  Dampness  and  defi- 
ciency of  light ;  3.  Other  unfavorable  hygienic  conditions;  among 
them,  frequent  intermarriage  of  near  relations  in  a  stationary 
population. 

In  the  treatment  of  goitre,  iodine  has  had  the  reputation  of  a 
specific.  It  is  not,  however,  infallible.  In  India,  the  external 
application  of  biniodide  of  mercury  is  much  employed.  Dr. 
Stevens,  of  Canada,'  states  that  he  has  found  very  satisfactory 
results  to  attend  the  use  of  chloride  of  amvionium,  in  goitre.  Dr. 
Woakes^  reports  the  cure  of  seventeen  cases  in  twenty  under  the 
use  of  fluoric  acid,  in  doses  of  from  15  minims  to  a  fluidrachm, 
thrice  daily,  largely  diluted  with  water.  Dr.  Giiggenbuhl  many 
years  since  proved  that  the  best  management  for  goitrous  and  cretin 
children  is  to  remove  them  from  their  valley  and  village  homes,  to 
high,  airy,  and  light  situations,  and  there  to  give  them  good  food, 
exercise,  and  other  appliances  of  a  health-producing  regimen. 

Dr.  Warren  Greene**  reports  the  successful  excision  of  the 
enlarged  thyroid  gland,  in  three  cases.  Desault  first  performed 
this  operation  with  success  ;  Dr.  C.  Harris,  of  ISTew  York,  operated 
successfully,  in  1807  ;  Gooch  and  Dupuytren  failed  with  it ; 
Hedenus,  of  Dresden,  succeeded  with  it  in  six  cases. ^  Billroth 
extirpated  seven  goitres  in  a  single  year.  It  is  certainly  an  opera- 
tion of  much  seriousness,  to  be  thought  of  only  in  cases  of  great 

1  Medical  Gazette  (New  York),  Jan.  3, 1880,  p.  16. 

2  Brit.  Med.  Journal,  July  20,  1878. 

3  Dr.  J.  St.  Lager  asserts,  after  careful  geological  exploration,  that  the  soil  ■where 
goitre  prevails  always  contains  iron  pyrites;  frequently  also  copper  pyrites, galena,  and 
baryta. 

4  Canada  Med.  Record,  February,  1880.  6  Lancet,  Vol.  I.,  1881,  p.  497. 
6  Am.  Jounial  of  Med.  Sciences,  Jan.,  1871,  p.  80. 

1  Copland,  I)i(^tionary  of  Medicine,  art.  Bronchocele.  See  also  an  article  on  Bron- 
chocele  by  the  authur,  in  Reynolds'  System  of  Medicine,  American  edition,  Vol.  III. 


536  DISEASES    OF    THE    SKIN. 

and  troublesome  enlargement.  Liicke,^  of  Berne,  asserts  success 
with  injections  of  tincture  of  iodine  into  the  tumor.  Injections 
of  ergotin  are  reported  very  favorably  of  by  others, 

DISEASES  OF  THE  SKIK. 

While  much  has  been  done  within  a  few  years  to  increase  our 
knowledge  of  the  true  pathology  and  relations  of  cutaneous 
diseases,  no  such  'perfection  of  classification  has  yet  been  reached, 
as  to  do  away  witli  the  practical  advantage  of  the  old  method  of 
describing  them  according  to  their  more  obvious  characters. 

As  a  clinical  classification  of  cutaneous  disorders,  most  conven- 
ient both  for  description  and  treatment,  I  prefer  the  following : — 

Exanthemata.  Pustulee.  Tubercula. 

Papulse.  Squamse.  Hsemorreagi^e. 

Vesiculse.  Maculse.  Neuroses. 

Bullae.  Hypertrophise.  Parasiticse. 

Syphilida. 

EXANTHEMATA. 

In  these  there  is  active  congestion,  or  hypersemia,  of  the 
"derma,"  or  true  skin.  Besides  scarlatina,  measles,  and  erysip- 
elas, already  considered,  this  order  contains  erythema,  urticaria, 
and  roseola. 

Erythema. — Superficial,  circumscribed  red  patches,  of  variable 
shape  and  size,  on  the  face,  trunk,  or  limbs,  not  painful,  nor  very 
sore,  characterize  this.  Its  causes  are,  all  moderate  but  continued 
irritants  to  the  skin.  Its  duration  is  generally  but  for  a  few  days 
or  a  week  or  two.  No  fever  attends  it ;  nor  is  it  either  contagious 
or  dangerous. 

Varieties^  of  erythema  are  erythema  fugax,  or  fleeting ;  erythema 
intertrigo^  from  friction  of  two  surfaces  of  the  skin,  as  in  not 
well-cleaned  children ;  erythema  rheumatica,  occurring  now  and 
then  in  rheumatic  fever;  erythema  pernio,  orunabraded  chilblain  ; 
erythema  nodosum  {hiYes),  on  the  legs,  with  rounded  node-like  prom- 
inent red  patches,  somewhat  more  inflamed  than  in  the  other 
forms  ;  and  erythema  tumescens,  with  a  more  diffused  inflammation 
of  the  subcutaneous  connective  tissue.  Drugs,  as  copaiba,  qui- 
nine, chloral,  strychnia,  salicylic  acid,  iodides,  bromides,  and 
others,  have  been  often  known  to  produce  erythema.  Quinine 
is  particularly  apt  to  have  this  effect  upon  some  persons  ;  the 
rash  having  a  certain  degree  of  resemblance  to  that  of  scarlet 
fever.  (Sometimes  it  is  vesicular  ;  approaching  the  appearance  of 
eczema.) 

Treatment  of  erythema  must  depend  upon  its  cause  more  than 
upon  its  particular  form.  The  stomach  and  bowels  may  need 
attention,  witli  the  use  of  antacids  and  laxatives  ;  especially  mag- 
nesia and  rhubarb,  or  Eochelle  salts,  or  the  citrate  of  magnesium. 

Local  applications  may  be,  finely-powdered  starch  or  ar]:ow- 

1  Lancet,  Jan.  2,  18G9.    iJ.  Mackenzie  injects  solution  of  perchloride  of  iraii. 

2  Here,  as  in  treating  of  other  affections  of  the  skin,  only  tlje  ^rirpfii^af^  v,aj;ipties  are 
named.    Wilson  makes  sixteen  varieties  of  erythema. 


PAPUT.iE.  537 

root,  dusted  on,  dry;  cold  cream  (unguent,  aq.  ros.);  lime-w:iter 
and  oil,  equal  parts  (olive  or  lard  oil);  vaseline  (unguentuni 
petrolei);  glycerin  and  prepared  chalk  ;  ointment  or  glyceritc  of 
zinc  [F.  177, 17K,  17i),  180,];  glycero-cerate  of  lead  ;  orglvceramyl 
[F.  148]. 

For  erythema  i)ernin^  or  frost-lnte  of  mild  degree,  astringents 
ai"e  serviceal)le  ;  as  bathing  the  feet  in  tepid  infusion  or  decoction 
of  oak-bark;  or  solution  of  alum  ;  or  applying  cerate  or  glycerite 
of  carbonate  of  l(?ad.     Some  recommend  cabbage-leaves, 

"Urticaria. — Nettle-rash.  Elevated,  round  or  oval,  red  or  white 
patches  or  wheals  characterize  this.  They  may  come  and  go  in 
an  hour,  over  the  arms,  trunk,  or  legs.  Much  burning,  stinging, 
or  itching  attends  them.  The  aflection  commonly  lasts  only  a 
week  or  two  ;  sometimes  it  is  chronic  and  tedious. 

Disorder  of  the  stomach  (as  from  unwholesome  food")  is  rather 
more  likely  to  cause  nettle-rash  than  any  other  kind  of  eruption. 
Mild  purgatives,  especially  salines  or  the  antacid  magnesia,  with 
or  without  powdered  charcoal,  are  commonly  suitable  for  it,  after 
a  dose  (two  or  three  grains)  of  blue  mass.  Light  diet  is  necessary. 
"Vinegar  and  water,  glycerin  and  rose-water,  or  the  starch-powder, 
etc.,  mentioned  for  erythema,  will  answer  for  local  applications. 
Much  use  of  cold  lotions  should  be  avoided,  lest  the  eruption  be 
over-hastily  repelled,  inducing  gastric,  hepatic,  or  other  internal 
disturbance  instead. 

Roseola. — Bright,  and  yet  generally  dark  red,  damask  rose- 
colored  patches,  irregular  in  shape  and  of  various  size,  over  any 
part  of  the  body,  without  much  if  any  fever,  belong  to  this  affec- 
tion. It  is  generally  of  but  a  few  days'  duration.  Sometimes  a 
certain  amount  of  resemblance  is  presented  by  it  to  scarlet  fever 
or  measles  ;  but  the  peculiar  sore-throat  of  the  former,  and  the 
catarrhal  symptoms  of  the  latter,  are  wanting.     (See  EdtheJn.) 

Scarcely  any  treatment  is  called  for  in  roseola ;  no  local  appli- 
cation, as  the  rash  is  but  slightly  irritating  ;  and  only  such  medi- 
cine as  the  general  condition  of  the  patient  may  indicate. 

PAPUL.ffi. 

These,  pimphi  eruptions,  involve  deioositive  inflammation  of  the 
skin,  which  is  raised  in  small,  red,  round,  or  conical  points  or 
minute  tubercles,  not  very  hard,  and  often,  though  not  always, 
transitor3\  Papular  aft'ections  are  lichen  and  strophidus.  Several 
dermatologists  now  classify  these  as  varieties  oferse7na  papidosum. 

Lichen. — ^Pimples  numerous,  but  of  small  size  ;  red,  and  more 
or  less  heated  and  irritated.  The  principal  forms  of  it  are  lichen 
simplex,  connnon  on  the  face,  neck,  etc.,  lichen  tropicus,  ov  pricldy 
heat,  and  lichen  agrius.  The  last-named  is  the  most  inflamed  and 
painful ;  sometimes  quite  severe.  Lichen  siriiplex,  though  mild, 
may  be  obstinate  in  its  persistence ;  annoying  ladies  occasionally 
by  remaining  long  on  the  face.  As  with  eczema,  some  authors 
assert  the  frequent  association  of  a  lichenoid  eruption  with  the 
gouty  diathesis.  In  lichen  tropicus,  from  which  children,  espe- 
cially, often  suffer  in  summer-time,  the  eruption  is  not  prominent, 
but  the  sense  of  irritation  is  very  unpleasant. 

Lichen  agrius  may  become,  in   violent   or  neglected  cases,  a 


538  DISEASES    OF    THE    SKIN. 

scabby,  confluent  eruption,  with  cracks  or  fissures,  and  a  serous, 
perhaps  purulent  discharge.     This  is  not,  however,  very  common. 

Treatment. — Even  for  the  simple  form,  and  still  more  for  1. 
agrius,  constitutional  alteratives  are  likely  to  be  needed,  doing 
more  good  than  local  applications.  In  1.  tropicus,  starch-powder, 
glycerin  and  rose-water,  or  glyceramyl,  or  weak  lead-water  will 
suffice,  without  any  medicine.  But  in  the  other  forms  rectifica- 
tion of  any  error  of  balance  in  the  system  must  first  be  made. 
The  plethoric  must  have  low  diet ;  the  anaemic,  lean  meat,  per- 
haps bitters,  aromatic  sulphuric  or  nitric  acid,  or  iron.  Costive- 
ness  must  be  overcome,  as  by  cream  of  tartar  and  sulphur,  rhu- 
barb and  aloes,  or  other  mild  but  decided  laxatives.  Blue  mass 
may  be  given,  a  grain  twice  daily  for  two  or  three  days.  Then 
arsenic  may  be  prescribed ;  of  Fowler's  liq.  potass,  arsenit.  three 
drops  twice  daily  at  first,  increased  every  week  one  drop  until 
ten,  twice  daily,  have  been  taken ;  omitting  the  remedy  if  head- 
ache, nausea,  diarrhoea,  or  puffiness  of  the  face  occur. 

In  lichen  agrius,  rest  in  bed  may  be  required ;  with  lime-water 
and  oil  dressing,  or  poultices  of  bread  and  milk,  or  flaxseed  meal, 
or  slippery  elm  bark  powder,  glyceramyl,  etc. 

Strophulus. — Red  gum  is  a  common  name  for  this  papular 
eruption  of  infancy.  Indigestion,  reflex  irritation  from  denti- 
tion, and  over-thick  clothing  or  living  in  hot  rooms,  produce  it. 
The  eruption  is  not  severe,  consisting  of  many  small  red  pimples, 
close  together,  and  often  nearly  all  over  the  body.  Attention  to 
the  stomach  and  bowels  is  necessary.  Lancing  the  gums  is  proper 
(all  authorities  to  the  contrary  notwithstanding)  if  they  be  swol- 
len, tender,  or  so  tense  as  evidently  to  distress  the  child.  To 
the  rash,  only  very  soothing  applications  should  be  made,  as 
starch-powder,  ointment  of  oxide  of  zinc  [F.  181],  or  glycer- 
amyl. Care  with  the  diet,  if  fed  instead  of  being  nursed,  is  also 
of  great  importance. 

VESICXIIJE, 

These  are  effusive  inflammations  of  the  derma ;  characterized 
by  numerous  and  small  water-blisters ;  the  smallest  are  suda- 
mina;  the  largest,  herpes ;  eczema  having  vesicles  of  intermediate 
size,  and  scattered.  Sudamina  are  met  with  in  low  fevers,  con- 
sumption, etc.,  mostly  when  perspiration  alternates  with  the 
febrile  state  in  an  enfeebled  system,^ 

Eczema. — This  has  been  the  subject  of  much  disputation ;  as 
to  whether  it  is  a  disease  per  se,  going  through  stages  not  only 
of  effusion,  but  also  of  incrustation,  suppuration,  desquamation, 
etc. ;  or,  only  a  phase  of  cutaneous  irritation  and  inflammation, 
called  vesicular,  whatever  its  cause,  and  eczematous,  to  distin- 
guish it  from  the  herpetic  eruptions.  I  am  satisfied  that,  while 
the  eczematous  vesicular  eruption  admits  of  a  very  distinct 
description  and  recognition,  it  may  come  from  or  after  a  papular 
rash,  and  may  in  the  same  case  be  transformed  (or  progress)  into 

1  Von  Barensprung  has  suggested  that  sudamina  may  be  owing  to  the  detention  of 
pprspiration  under  the  cuticle,  from  obstruction  of  the  ducts  of  the  sudoriparous 
glands. 


VESICUL7E.  539 

a  pustular  or  scabbing  disease.  H(;bra  and  many  other  author- 
ities in  dermatology  atfirni  this  to  be  the  true  account  of  its 
common  history.  In  the  language  of  Erasmus  Wilson,'  "It  is 
a  superficial  and  chronic  intlammation  of  the  skin,  with  a  ten- 
dency to  the  exudation  of  an  ichorous  fluid;  the  fluid  being 
sometimes  detained  in  minute  vesicular  elevations  of  the  epi- 
d(!rmis,  sometimes  free,  and  sometimes  infiltrated  in  the  tissues 
of  the  skin." 

Golding  Bird  and  Mapother  have  insisted  that  the  (jouty  dia- 
thesis has  to  do  with  chronic  eczema.  Routh  calls  attention  to 
its  not  infrequent  dependence  on  nervous  exhaustion  (aneuresis, 
neurasthenia). 

Eczema  simplex,  mhrum,  infantile,  and  impetiginorles,  are  itS' 
principal  varieties.  Besides  others  named  in  the  books,  there 
are  also  eczema  solare,  from  heat,  and  eczema  mercurialis,  from 
the  impression  of  mercury  on  the  system.  The  simple  form  has 
but  little  inflammation ;  but  there  is  always  some  soreness,  and 
the  vesicles  ma}^  run  together  and  break,  oozing  serum  or  lymph, 
or  scabbing  lightl}'.  Eczema  rubrum  is  more  inflamed,  with  red- 
ness, heat,  and  some  tumefaction.  Crusta  lactea,  or  milk  crust,  is 
a  name  often  given  to  eczema  infantile,  of  the  nursing-time.  It 
affects  the  face,  sometimes  very  lui pleasantly  ;  scabbing,  running, 
and  cracking  all  over  it.  E.  impetiginodes  appears  to  be  an 
intermediate  stage,  or  transition,  between  eczema  and  impetigo ; 
water-blisters  appearing  at  first,  and  pustules  afterwards. 

Treatment. — An  inflammator}''  state  attends  the  eczematous 
eruption,  nearly  alwa5's ;  especially  in  e.  ruhrtim  and  advanced 
crusta  lactea.  Saline  laxatives,  diuretics,  and  diaphoretics  (Ro- 
chelle  salts,  bitartrate  of  potassium,  citrate,  etc. )  are  often  called 
for,  perhaps  to  be  repeated  in  moderate  doses.  Light  diet  is,  in 
like  case,  proper.  In  children,  small  doses  of  calomel  occasion- 
ally do  good.  Locally,  weak  lead-water  when  there  is  no  scab- 
bing ;  lime-water  and  oil  when  there  is  great  imtation  ;  decoction 
of  bran ;  flaxseed  infusion  with  bicarbonate  of  sodium  Oj  in 
fgiv) ;  glyceramyl  ;^  glycerin  with  rose-water ;  solution  of  sul- 
phite of  sodium  Oj  in  f§j);  carbonate  of  lead  cerate  ;  benzoated 
vaseline  ;  ointment  of  oxide  of  zinc  :^  these  are  among  the  many 
applications  used  with  advantage.  McCall  Anderson  advises, 
in  chronic  eczema,  a  preparation  of  carbolic  acid  in  glycerin  and 
alcohol.*  The  whole  bath,  tepid  or  slightly  warm  (never  hot), 
two  or  three  times  a  week,  will  be  beneficial.  In  chronic  eczema, 
the  "  Turkish  "  or  dry  hot-air  bath  (1.30°  to  150°)  is  highly  recom- 
mended by  some.  Hardy  and  Hebra  have  made  considerable 
use  of  a  covering  of  India-rubber  cloth  over  the  parts  affected ; 
removed  daily  for  thorough  cleansing.     This  is  thought  to  be 

1  Journal  of  Cutaneous  Medicine,  April,  ISfiO. 

2  Or  the  following :  Rub  together  in  a  mortar  four  parts  of  yolk  of  egg  with  five  parts 
of  Bower's  or  Price's  glycerin.  This  has  the  advantage  over  unguents  of  being  remov- 
able by  water. 

3  Benzoated  ointment  of  oxide  of  zinc  is  regarded  by  E.  Wilson  as  a  "specific"  for 
eczema  in  its  advancing  stages. 

■•  Oy.stallized  carbolic  acid,  2  drachms;  glycerin, 6  drachms;  rectified  spirit, 4  ounces; 
distilled  water,  1  ounce.    Sponge  with  this  solution  two  or  three  times  daily. 


540  DISEASES    OF    THE    SKINo 

especially  available  for  the  hands,  feet,  and  scrotum.  Martin's 
elastic  rubber  bandage  is  preferred  by  Bruns,  of  Tiibingeno  Bus- 
quet^  has  especially  urged  the  value  of  occlusion  in  the  treatment 
of  chronic  skin  diseases.  The  "Vienna  plan"  is  to  strap  the 
affected  part  with  strips  of  linen  spread  with  lead  plaster.  Elec- 
tricity is  sometimes  a  useful  part  of  the  treatment.  Possibly  the 
jaborandi  {pilocarpus  pinnatus)  of  Brazil,  a  powerful  diaphoretic, 
or  its  active  principle,  pilocarpine  may  be  found  to  have  a  service- 
able alterative  action  upon  the  skin  in  this  affection,  Piffard'' 
and  Kaposi  recommend  an  unguent  made  of  equal  parts  of  lead 
plaster  and  vaseline,  incorporated  together  with  the  aid  of  heat. 

Chronic  eczema  requires  alterative  treatment  internally.  Ar= 
senic  is  the  alterative,  par  excellence,  in  obstinate  cutaneous  affec- 
tions. Its  peculiar  action  on  the  skin  tends  to  displace  the  morbid 
process,  and  thus  to  restore,  after  its  own  transient  influence  is 
withdrawn,  healthy  nutrition  and  reparation.  Five  drops  of 
Fowler's  solution  (or  the  liquor  arsenici  chloridi  of  U.  S.  P.,  equal 
in  strength  to  liq.  potass,  arsenit. )  may  be  given  at  first,  twice 
daily,  increased  gradually  until  the  dose  amounts  to  ten  drops  ; 
sometimes  even  more.  The  medicine  must  be  intermitted  if  the 
head,  stomach,  or  bowels  show  its  decided  action.  In  case  of  its 
failure,  particularly  where  syphilitic  taint  is  possible,  Donovan's 
solution  (liq.  arsenici  et  hydrargyri  iodidi)  may  be  given ;  three 
drops  at  first,  cautiously  increased.  A  combination  of  arsenic 
with  iron  has  lately  been  much  commended.  Scrofulous  or  other- 
wise feeble  children  may  need  cod-liver  oil.  In  crusta  lactea  or 
eczema  infantile,  the  mother  or  nurse  must  be  instructed  not  to 
burden  the  child  with  clothes,  nor  keep  it  in  an  overheated  room. 
Daily  bathing  is  particularly  important  to  an  infant  suffering  with 
such  an  eruption.  Dr.  Bulkley,  of  New  York,  speaks  highly  of 
the  use,  in  obstinate  chronic  eczema,  of  liquor  picis  alkalinus  [P. 
263].  If  a  case  of  chronic  eczema  is  first  seen  late  in  the  attack, 
the  removal  of  the  scabby  crust  may  be  important.  In  mild  cases, 
poultices  of  bread  or  flaxseed  meal  may  suffice  for  this.  If  very 
thick,  the  scab  may  be  softened  by  the  application,  two  or  three 
times  daily,  of  a  wash  of  one  part  of  liquor  potassse  with  ten  parts 
of  olive  oil.  After  this,  many  practitioners  apply  dry  lint ;  some, 
thin  India-rubber  cloth ;  others,  one  of  the  unguents  above 
mentioned. 

Herpes. — This  has  larger,  more  separated,  and  less  numerous 
vesicles  than  eczema ;  it  is  less  apt  to  become  chronic.  Varieties : 
herpes  phlyctenodes,  herpes  zoster ,  and  herpes  circinatus.  The  first 
is  the  most  frequent ;  receiving  also  local  names  according  to  its 
seat :  as  h.  labialis,  proiputialis,  etc.  Herpes  labialis  is  commonly 
called  "fever  blisters." 

Herp)es  zoster  (Shingles)  is  not  very  common.  Half  of  the  body, 
about  tlie  waist,  is  covered  with  vesicles,  on  an  inflamed  red 
surface.  Sometimes  neuralgic  pains,  quite  severe,  attend  it.  It 
generally  affects  the  right  side.  Its  duration  is  but  for  a  week  or 
two ;  unless  in  the  feeble  or  old,  in  whom  it  may  be  followed  by 
ulcerations  of  a  tedious,  perhaps  dangerous  character. 


iLyon  Medical,  April  10,  1881.  2  Archives  of  Dermatology,  1876. 


B  U  L  L  iE.  541 

Herpes  circinatus  is  distributed  in  circular  patches  or  rings. 
Minute  vesicles  appear  around  the  circumference.  By  these,  and 
the  absence  of  microscopic  vegetation,  and  less  disposition  to 
chronicity,  it  is  distinguished  from  tinea  tonsurans^  or  true  conta- 
gious ringworm.  Herjies  iris,  of  writers,  is  an  aborted  /i„  circi- 
natus; the  rings  being  incompleteo 

Herpes  rarely  appears  in  old  persons ;  often  in  children  and 
adolescents.  AH  causes  of  irritation  of  the  surface  of  the  body 
may  induce  it :  as  febrile  or  catarrhal  attacks,  stimulating  diet, 
violent  exercise,  etc. 

For  the  treatment  of  herpes,  the  plan  stated  for  eczema  is,  in 
principUi,  here  also  suitable.  Cucumber  ointment  may  be  added 
to  the  applications  recommended.  Herpes  zoster  requires  confine- 
ment to  bed.  The  severe  pains,  in  this,  may  call  for  anodynes. 
Purdon  and  others  give  also  for  it  ergot  and  iron  ;  viewing  it  as 
essentially  a  neurosis.  Belladonna  ointment  is  a  good  local  appli- 
cation for  it.  Tincture  of  chloride  of  iron  is  locally  used  for  it 
by  Baudon  and  others.  Herpes  lahialis  is  sometimes  very  annoy- 
ing, especially  to  ladies.  Pure  cologne-ioater,  applied  at  the  very 
start,  may  abort  the  vesicles.  Magnesia  powder  is  used  by  some 
to  dust  about  the  lips.  Calomel  ointment  is  recommended  when 
the  eruption  is  chronic,  coming  out  in  successive  crojDS. 

BULL.ffi. 

These  are  eruptions  of  large  vesicles.  Pemphigus  and  Bupia 
are  the  most  distinct. 

Pemphigcus. — Bullee  of  a  circular  or  oval  shape,  from  lialf  an 
inch  to  two  inches  in  diameter,  and  flattened.  They  may  be 
distributed  over  any  or  all  parts  of  the  body.  Fever,  sometimes 
considerable,  precedes  and  accompanies  the  eruption.  I  have 
seen  it  as  a  very  serious  illness  (pemphigus  malignus).  After  the 
vesicles  mature,  they  burst,  or  dry  away,  leaving  thin  brown 
scabs.  Ulceration  may  occur,  but  it  is  not  deep  or  obstinate, 
unless  in  a  particularly  unhealthy  constitution,  The  duration  of 
pemphigus  is  from  one  to  three  weeks,  or  more  in  bad  cases. 
Pompholyx  is  the  name  given  to  a  rare  variety  of  pemphigus,  in 
which  the  space  continuously  covered  by  bullae  is  large,  and  there 
is  little  or  no  fever.     A  fly-blister  causes  artificial  pompholyx. 

Pemphigus  is  not  usually  considered  to  be  contagious.  One 
fjimily  came  under  my  notice,  however,  in  which  five  individuals 
were  attacked  by  it,  partly  in  succession,  after  travelling.  It  was 
difficult  in  that  case  not  to  suppose  contagion. 

In  the  treatment  of  pemphigus,  gently  refrigerant  laxatives  at 
first,  diuretics  and  diaphoretics  next,  and  often  quite  early  tonics 
and  supporting  regimen,  are  called  for.  English  observers  assert 
the  good  efiect  of  arsenic  in  pemphigus ;  some  European  authori- 
ties, as  Hebra  and  Hardy,  deny  its  efficacy.  In  one  acute  case  I 
was  obliged  to  stimulate  quite  freely  ;  the  eruption  being  as  con- 
fluent as  in  any  case  of  small-pox,  and  prostrating,  like  an  exten- 
sive burn.  Jonathan  Hutchinson  asserts  that  arsenic  exercises 
a  special  control  over  pemphigus.  Dr.  L.  D.  Bulkley  has  reported 
46 


542  DISEASES    OP    THE    SKIN. 

a  case  ^  of  malignant  pemphigus  in  which  arsenic  appeared  to 
save  the  patient's  life.  No  local  applications,  other  than  the 
mildest  lotions  or  unguents,  will  be  suitable.  The  early  puncture 
of  each  bulla  with  a  small  needle  is  recommended  ;  but  the  raised 
cuticle  must  not  be  removed. 

Kupia  is  probably  but  a  modification  of  pemphigus ;  with 
smaller  blebs  or  bullae,  followed  by  thicker  conical  scabs  of  dark 
color  ;  after  whose  removal  ulcers  are  left,  which  may  be  weeks 
in  healing.  Rupia  simplex  is  the  variety  in  which  the  scabs  are 
low  and  the  ulcers  slight ;  rupia  prominens^  in  which  they  are 
elevated  into  irregular  cones  ;  rupia  escharotica^  when  the  ulcera- 
tion is  deep  and  extended.  Syphilitic  rupia  is  quite  common ; 
but  every  case  of  rupia  is  not,  by  authorities,  admitted  to  be 
syphilitic.     My  observation  goes  to  sustain  this  non-admission. 

Treatment  of  rupia  requires  to  be,  generally,  tonic  and  alter- 
ative. Quinine,  cod-liver  oil,  and  iodide  of  potassium,  with  good 
but  simple  diet,  are  apt  to  be  wanted  for  it.  In  prolonged  cases, 
arsenic  and  iron  may  be  given  at  the  same  time,  or  in  combination. 

PUSTUL^E. 

Suppurative  inflammation  of  the  skin  (excluding  small-pox, 
furuncle,  and  carbuncle,  as  well  as  the  malignant  pustule  or 
charbon  of  the  French,  a  rare  affection  said  to  be  received  from 
cattle)  appears  in  the  two  forms  ecthyma  and  impetigo. 

Ecthyma. — Large,  round,  prominent  pustules,  upon  any  part 
of  the  body,  not  numerous ;  ending  in  thick  dark  scabs,  followed 
by  slight  (or  in  cachectic  states,  obstinate)  ulcerations.  Oint- 
ment of  tartar  emetic,  or  pure  croton  oil,  or  other  strong  cutane- 
ous irritants,  will  produce  it.  Often,  however,  especially  in 
syphilitic  persons,  or  after  acute  fevers,  etc.,  it  occurs  without 
any  local  exciting  cause.     Sometimes  it  is  chronic. 

In  treatment  the  causation  is  of  great  importance.  If  a  local 
irritant  produce  it,  local  emollients,  perhaps  with  general  refrig- 
erants, are  to  be  used  for  its  relief.  Otherwise,  diet  and  halancive 
measures  will  be  more  in  place ;  tonics  for  the  feeble,  purgatives 
and  light  regimen  for  the  plethoric,  etc. 

As  an  eliminant  and  refrigerant  in  both  ecthyma  and  impetigo 
(as  well  as  rupia)  I  have  found  apparent  benefit  from  the  use  of 
a  prescription  employed  by  Dr.  Anderson,  of  Scotland ;  equal 
parts  of  wine  of  colchicum,  and  wine  of  ipecac,  say  ten  drops  of 
each,  thrice  daily  [F.  182].  Arsenic  is  called  for  in  obstinate 
cases,  as  in  other  diseases  of  the  skin ;  Fowler's  or  Donovan's 
solution,  in  small  doses,  carefully  increased. 

Impetigo. — Small  and  somewhat  numerous  pustules ;  varieties, 
impetigo  figurata  and  impetigo  sparsa.  I.  fiyurata  is  most  common 
on  the  face,  in  circumscribed  clusters  of  pustules,  which  may 
become  confluent  and  scab.  To  this,  in  children,  as  well  as  to 
eczema  infantile,  the  name  of  crusta  lactea  is  given  by  many 
authors.  I.  spjarsa  has  the  pustules  scattered  over  more  or  less 
of  the  whole  body.     Impetigo  contagiosa  is  named  and  described 

1  Amer.  Journal  of  Med.  Sciences,  Oct.,  1877. 


s  Q  u  A  M  ;e.  543 

by  Tilbury  Fox.'  It  is  not  common,  but  I  have  known  cases  to 
which  the  term  mi^ht  well  apply.  I)r.  Fox  finds  it  to  be  quite 
curable  by  the  application  of  a  weak  ointment  of  ammonio- 
cliloride  of  mercury  to  the  ulceration  that  occurs  under  the 
scabs.  Several  leading  modern  authorities  (Hardy,  Ilebra, 
Wilson)  regard  impetigo  as  only  a  stage  or  variety  of  eczema. 

Treatment. — When  much  irritation  or  inllammation  exists, 
lead-water,  glyceramyl,  ointment  of  oxide  of  zinc,  lime-water 
and  olive  oil,  fiaxseed  tea  and  bicarbonate  of  sodium,  light  poul- 
tices of  flaxseed  meal,  slippery  elm  bark,  or  bread  cruml),  are  to 
be  applied.  Daily  use  of  castile  soap  and  water  is  serviceable. 
Besnier's  method  is  to  envelope  the  whole  of  the  aftected  parts 
with  India-rubber  cloth.  This  treatment  is  a  good  deal  used  in 
Paris.  Purgatives  may  be  needed.  Diet  must  be  according  to 
the  general  condition  of  the  patient.  Impetiga  may  aftect  the 
hairy  scalp ;  if  so,  the  hair  must  be  cut  and  kept  very  short. 
Colchicura  and  ipecac,  may  be  given  in  acute  cases  [F.  182]; 
arsenic  in  those  which  become  chronic. 


SftUAMa:. 

Scaly  diseases  ai'e  Lepra  {Alphas  of  Wilson),  Psoriasis,  Leprosy 
of  the  Hebrews,  Spedalsked  or  Norwegian  leprosy.  Pityriasis,  Pel- 
lagra, and  Ichthyosis. 

Lepra. — Always  chronic,  and  very  difficult  to  cure.  Not  re- 
garded as  contagious,  though  I  have  seen  it  occur  successively 
in  four  persons  in  immediate  contact  (an  infant  at  the  breast,  its 
wet-nurse,  another  infant  suckled  by  her,  and  her  husband).  It 
is  characterized  by  red  desquamating  patches,  of  various  sizes, 
approximating  to  a  circular  shape,  on  any  part  of  the  body, 
especially  on  the  arms  and  legs.  Besides  syphilitic  lepra,  its 
varieties  are  lepra  vulgaris,  with  small  patches  and  few  thin 
scales,  and  lepra  inveterata  [alphos  diffusus  of  Wilson),  where  they 
are  large  and  desquamate  extensively. 

In  both,  the  margin  of  the  patch  is  the  highest,  reddest,  and 
most  squamous  part. 

Psoriasis. — Described  under  the  names  of  ps.  mdgaris,  gyrata, 
and  inveterata,  psoriasis  diflers  mainly  from  lepra  in  the  irregular 
and  varied  forms  of  the  desquamating  patches,  and  in  the  absence 
or  less  degree  of  depression  near  their  centres.  Wilson's  view, 
that  psoriasis  is  only  a  kind  of  chronic  eczema,  does  not  seem  to 
me  to  accord  with  the  facts  of  its  ordinary  history.  It  is  some- 
times hereditary ;  as  is  also  lepra.  Bence  Jones  has  suggested 
its  possessing  some  relation  to  the  rheumatic  diathesis.  No 
disease  of  the  skin  is  so  hard  to  eradicate,  unless  it  be  ichthyosis. 
Tilbury  Fox  asserts  that  it  is  much  more  common  in  England 
than  elsewhere. 

Treatment. — For  lepra  and  psoriasis  alike,  all  sorts  of  alterative 
agencies,  local  and  systemic,  are,  if  cautiously  used,  suitable  for 
tentative  practice.  Our  object  is  to  obtain  the  making  of  a  new 
ski)i  unaffected  by  the  morbid  habitude  of  nutrition.     Frequent 

1  Journal  of  Cutaneous  Medicine,  October,  1869. 


544  DISEASES    OF    THE    SKIN, 

bathing  should  be  practised.  Tar  ointment,  citrine  ointment, 
ointment  of  sulphuret  of  potassium  [F.  183] ,  etc.,  may  be  applied. 
Buck,  of  Liibeck,  uses  acetic  acid  locally.  Ointment  of  cryso- 
phanic  acid  has  latterly  been  used,  with  considerable  asserted 
advantage,  in  treatment  of  psoriasis.  It  is  a  powerful  irritant, 
and  discolors  the  skin.  The  strength  of  twenty  grains  to  the 
ounce,  used  by  some,  is  probably  too  great.  From  five  to  ten 
grains  in  the  ounce  of  lard  or  vaseline  will  be  sufficient.  Pyro- 
galUc  acid  (Jarisch)  also  is  used  in  ointment,  and  more  frequently 
in  a  ten-per-cent.  solution.  It  requires  careful  limitation,  as  a 
death  has  been  reported^  from  the  application  of  a  ten-per-cent. 
salve  of  it  over  half  of  the  body  of  a  patient.  Arsenic,  and  the 
iodide  of  arsenic  and  mercury  (Donovan's)  should  be  given,  care- 
fully, but  repeatedly,  through  long  periods.  Wilson  and  others 
latterly  give  a  combination  of  arsenic  with  iron.  Other  medica- 
tion must  depend  upon  the  conditions  of  each  case.  Dr.  Broad- 
bent^  has  proposed  phosphorated  oil,  in  four-  to  eight-minim 
doses,  for  the  treatment  of  psoriasis,  as  well  as  for  eczema, 
asserting  success  in  four  out  of  six  cases  of  the  former.  Hardy, 
besides  phosphorus,  uses  copaiba  internally  in  the  treatment  of 
psoriasis.^ 

Ichthyosis.  (Fish-skin  disease.) — This  is  rare.  I  have  seen 
but  one  case  of  it.  Hard,  thick,  dry  scales  form  continuously 
over  a  part,  or,  sometimes,  nearly  the  whole  surface,  of  the  body, 
without  much  redness,  soreness,  or  even  itching.  It  is  congenital 
and  incurable.  Frequent  and  thorough  ablutions  and  mild  emol- 
lient applications  (as  glyceramyl  or  benzoated  vaseline)  are  iialli- 
ative  of  it.  Intermediate  between  ichthyosis  and  the  normal 
state  of  the  skin  is  a  condition,  somewhat  less  intractable,  to 
which  the  term  xeroderma  (Lailler)  has  been  applied.  For  this 
especially,  glycerin  (Demarquay),  externally  applied,  appears  to 
be  useful. 

Pellagra  is  a  serious  constitutional  disease,  attended  by  a  scaly 
thickening  of  the  skin,  endemic  in  Northern  Italy,  France,  and 
Spain.  In  Italy  thousands  of  cases  of  it  occur  every  year.  Slow 
fever,  diarrhoea,  great  prostration,  and  sometimes  insanity,  are 
its  principal  symptoms.  They  usually  subside  in  the  autumn, 
to  recur  with  increasing  severity  with  spring.  Some  authors  have 
asserted  its  dependence  upon  "zeism,"  or  the  effect  of  the 
exclusive  use  of  maize  as  food ;  but  careful  investigation  shows 
that  its  cause  is,  more  probably,  a  parasitic  disease  of  the  corn, 
analogous  to  the  ergot  of  rye.  Pellagra  does  not  appear  to  be 
curable,  unless,  at  an  early  stage,  by  removal  from  the  influence 
of  its  cause. 

Pityriasis.  —This  is  a  chronic  aflfection  in  which  very  numerous 
small  white  scales  (dandriff")  form  upon  the  skin,  particularly  the 
scalp  (p.  capitis).  Seborrhcea,  i.  e.,  increased  secretion  of  the  seba- 
ceous glands,  is  its  pathological  cause.  Kenan  is  a  parasitic  aflfec- 
tion of  the  hair  follicles,  with  derangement  of  their  secretion.  It 
is  not  common.     Some  redness,  and  often  a  good  deal  of  itching, 

1  Neisser,  in  Berliner  Klin.  Wochensclirift,  November  24,  1879. 

a  Lancet,  April  22, 1871.  ^  Annales  de  Dermatologie,  etc.,  No.  6. 


S  Q  IT  A  M  JE.  545 

may  attend  it,  Dandriff  i^  difficult  of  cure  in  many  cases.  If  it 
be  upon  the  head,  keeping  the?  hair  sliort,  and  washing  daily  with 
castile  soap,  followed  l)y  a  spirituous  lotion,  or  glycerin  and  rose- 
water,  will  do  the  best  for  it.  Cleanliness  and  frequent  bathing 
in  tepid,  cool,  or,  if  the  vigor  of  the  system  permit,  cold  water,  are 
of  essential  importance  in  all  cases.  Pityriasis  rubra  is  described 
by  T.  Fox  as  characterized  by  superficial  hypersemia  of  the  skin, 
with  "  hyi)erplastic  growth  "  of  the  cuticle,  which  exfoliates  abun- 
dantly. It  occurs  especially  in  those  who  have  suffered  from  mental 
anxiety  or  overwork.  He  advises  diuretics  in  its  treatment.  P. 
rubra  is  not  common  in  this  country. 

The  term  2jU!/riasis  versicolor  is  sometimes  applied  to  an  einphytic 
disease  {i.  e.,  one  connected  with  a  vegetable  parasitic  growth), 
better  called  chloasma  versicolor. 

Spedalksed  is  a  disorder  known  in  Norway  and  Sweden ;  espe- 
cially among  the  fishermen.  It  is  also  met  with  in  Crete.  Full 
accounts  of  it  are  given  in  medical  journals  and  books,'  but  a  mere 
reference  to  it  will  suffice  here.     (See  Elephantiasis  Grcecoruvi.) 

Leprosy  of  the  Bible  (Lepra  Hebrteorum,  Morphoea)  is  of  great 
historical  interest.-'  It  is  still  recognizable  in  the  East,  though 
not  very  frequently  met  with.  In  the  Book  of  Leviticus,  three 
varieties  of  leprosy  are  described :  dull  or  darkish  white  "  freckled 
spots ;"  dusky  or  shadowed;  and  bright  white  {bahereth  lebliana), 
the  worst  of  all.  Tsorat  (whence  psora,  and  sore),  or  malignant 
disease,  was  applied  to  the  last  two  only.  Lepra  is  an  early 
Greek  synonym  of  this  term.  Mason  Good  thus  describes  the 
old  leprosy:  "A  glossy,  white,  and  spreading  scale  upon  an  ele- 
vated base;  the  elevation  depressed  in  the  middle,  but  without 
change  of  color;  the  black  hair  on  the  patches,  which  is  the  nat- 
ural color  of  the  hair  in  Palestine,  participating  in  the  whiteness, 
and  the  patches  themselves  perpetually  widening  their  outline." 
In  favorable  cases,  after  spreading  over  much  of  the  person, 
though  without  ulceration,  the  disease  would  die  out;  the  scales 
would  dry  up  and  gradually  disappear.  In  bad  cases,  ulceration 
would  occur,  with  extensive  sores,  as  well  as  desquamation. 
Then  the  leper  was  made  an  outcast,  and  trea-ted  as  one  dead; 
"  unclean  for  life." 

Not  only  the  books  of  Moses,  and  others  of  the  Bible,  but  also 
Hippocrates,  Galen,  and  Celsus  (under  the  names  /.evxtji  and  Mirpa 
7.ivx>i)  speak  of  ancient  leprosy  as  a  white  scaly  disease.  It  thus 
diflers  decidedly  from  either  kind  of  elephantiasis. 

The  report  of  a  Committee  of  the  London  College  of  Physicians* 
states  that  leprosy  now  exists  in  Egypt,  Abyssinia,  Algeria,  Mo- 
rocco, Senegambia,  Cape  of  Good  Hope,  Madagascar,  Mauritius, 
Isle  of  Bourbon,  Syria,  Arabia,  Persia,  Bokhara,  Cashmere,  India, 
Ceylon,  Java,  Sumatra,  China,  Kamskatka,  Australia,  ^gean 
Islands,  Crete,  Cephalonia,  Malta,  Greece,  Russia,  Esthonia,  Fin- 
land, Courland,  Sweden,  Norway,  Iceland,  coasts  of  North  Italy 
and  Southeastern   France,  other  shores  of  the  Meditei'ranean, 

1  See  Brit,  and  For.  Medico-Chirurg.  Rev.,  1850,  p.  71. 

-  See  Neligan's  Treatise  on  Diseases  of  the  Skin,  edited  by  Dr.  Belcber  (Philadelphia 
ed.,  l'6i;,  p.  -289). 
3  Med.  Times  and  Gazette,  Feb.  23,  1867. 

46*  2K 


546  DISEASES    OF    THE    SKIN. 

delta  of  the  Rhone,  Spain,  Portugal,  Mexico,  Brazil,  West  Indies, 
New  Granada,  Venezuela,  Ecuador,  and  La  Plata.  It  is  said  to 
be  on  the  increase  in  the  West  Indies,  and  has  been  known  recently 
in  New  Brunswick.^  A  number  of  cases  have  occurred  lately  in 
the  Sandwich  Islands ;  as  well  as  at  Key  West,  Florida.  At  New 
Orleans,  a  hospital  for  lepers  was  established  in  1778.  The  disease 
exists  in  two  forms  :  1.  Tubercular ;  2,  Non-tubercular.  Anaes- 
thesia of  the  skin  is  frequent  in  both ;  and  so  is  enlargement  of 
nerve-trunks. 

It  is  hereditary.  It  may  be  congenital ;  but  generally  begins 
about  puberty.  Bad  diet,  and  other  personal  xmsanitary  condi- 
tions, are  most  promotive  of  it.  Hygienic  improvements  prevent 
or  mitigate  it.  Medical  treatment  appears  to  be  generally  inca- 
pable of  curing  it.^  Qurjun  (dipterocarpus)  oil  and  chaulmoogra 
oil  have  been  much  used  for  it,  both  externally  and  internally,  in 
India  and  elsewhere.  Of  chaulmoogra  oil  (gynocardia  odorata) 
the  dose  at  commencement  is  5  minims.  The  bark  of  the  lioang- 
nan,  a  vine  of  Cochin  China  (strychnos  Gaultheriana),  in  3-grain 
doses,  is  also  said  to  be  serviceable  in  the  treatment  of  leprosy. 
Dr.  Simmons,  of  Yokohama,  Japan,  uses  for  it  copaiba,  inter- 
nally and  externally.  E.  Wilson^  gives  the  duration  of  tubercular 
leprosy  as  from  ten  to  fifteen  years;  of  the  anaesthetic,  fifteen  to 
twenty  years.  Life  may  last  under  it  for  five,  ten,  or  twenty 
years.  It  has  no  proved  connection  with  syphilis;  nor  is  there 
decisive  evidence  of  its  contagiousness.  Segregation  of  the  lep- 
rous does  good,  by  preventing  or  limiting  the  marriage  of  lepers. 
Climate  can  have  but  little  to  do  with  its  causation,  as  it  prevails 
in  places  as  remote  and  unlike  as  China  and  Norway;  late  writers 
asserting  the  identity  of  the  Norwegian  "spedalsked  "  with  the 
leprosy  of  other  places. 

Jonathan  Hutchinson*  reported  to  the  Royal  Medical  and 
Chirurgical  Society  a  well-marked  case  of  leprosy  in  which 
recovery  took  place.  He  attributed  her  cure  mainly  to  change 
of  diet,  especially  the  abandonment  of  fish.  The  first  recorded 
case  of  inherited  leprosy  in  the  United  States  is  said  to  have 
occurred  in  Nebraska,  being  reported  by  Prof.  Hyde,  of  Chi- 
cago.'' Altogether,  statistics  of  the  Dermatological  Society  make 
it  appear  that,  in  1880,  there  were  between  50  and  100  lepers  in 
tiie  United  States.  Although  not  contagious  in  the  ordinary 
sense,  after  getting  a  foothold  in  a  place,  it  appears  to  increase 
in  some  manner,  generally.  In  1840,  there  was  no  leprosy  in.  the 
Sandwich  Islands  ;®  having  been  brought  thither  since  by  the 
Chinese,  in  1880,  about  one-tenth  of  the  inhabitants  were  said  to 
be  lepers. 


1  A  pamphlet  has  been  written  by  Dr.  Brognat-Landre  on  its  prevalence  in  Surinam. 

2  Carbolic  acid,  externally  applied,  is  asserted  to  have  cured  some  cases.  Oil  of  cashew- 
nut  (Auacardium  occidentale;  has  acquired  some  reputation  in  Trinidad,  under  the 
hands  of  Dr.  Beauperthuy. 

3  Lectures  on  Dermatology,  Lancet,  February  and  March,  1873. 
i  Lancet,  Feb.  15,  1879. 

6  Chicago  Med.  Journal  and  Examiner,  December,  1879. 

*  This  statement,  however,  has  been  lately  denied  by  residents  of  those  islands. 


HYPEliTKOPUI^.  547 

'  MACULJE. 

Ephelis^  Vitilifjo,  and  Chloasma  may  be  included  under  this  term; 
perhaps  better  under  that  of  Decolorationes. 

Ephelis ;  lenthio. — Sunburn  and  freckles  best  correspond  with 
these  names,  which,  however,  are  by  some  authors  extended 
further.  Neither  are  of  importance,  unless  in  regard  to  api)ear- 
ance.  For  the  removal  of  freckles  (which  often  disappear  spon- 
taneously with  time)  or  the  yellowish  brown  spots  called  chloasDia, 
or  melasma,  all  applications  may  fail;  dilute  nitro-muriatic  acid 
(fifteen  to  thirty  drops  in  an  ounce),  left  for  some  time  in  contact 
with  the  discolored  spots,  is  more  likely  than  anything  else  to  take 
effect._  _  [See  F.  373.] 

Vitiligo. — Literally  veal-sMn.  Unnatural  whiteness  from  defi- 
ciency of  coloring  matter.  When  universal  over  tlie  body  (nearly 
always  then  congenital)  it  is  albinismus.  We  see  albinoes,  some- 
times families  of  them,  in  all  the  races  of  mankind  ;  as  well  as 
among  the  lower  animals.  Leucoderma,  Avhite  skin,  and  le2ico- 
pathia,  or  white  disease,  are  names  given  by  some  writers  to  both 
the  general  and  the  local  affection. 

When  local,  vitiligo  is  seen  mostly  in  rounded  patches  or  spots, 
which  slowly  increase  in  size,  though  without  regularity  of  shape. 
The  head,  chest,  back,  and  thighs  are  the  most  frequent  seats  of 
them.  The  hairs  on  the  parts  involved  become  white ;  or  fall 
out,  causing  baldness— ca?(.'ii<e«  or  alopecia. 

Treatment  for  vitiligo  must  be,  first,  general,  for  improvement 
of  nutrition  in  the  whole  system ;  and  then  local.  Very  hard  it 
may  be  to  cure  the  affection,  although  its  importance  is  chiefly 
for  appearance  ;  no  danger  attends  it.  Tannic  acid  and  oil  of 
turpentine  are  the  preferred  local  applications  for  it.  Total 
albinismus  is  quite  incurable. 

Chloasma  (pityriasis)  versicolor  will  be  spoken  of  under 
Parasitica. 

For  alopecia.,  baldness,  or  premature  loss  of  the  hair,  very  many 
remedies  are  in  vogue.  Shaving  the  head  repeatedly  [i.  e.,  after 
an  illness)  may  often  save  the  hair.  Stimulating  applications 
sometimes  help  and  sometimes  hurt  the  case  [F.  185,  186]. 

HYPERTKOPHI.ffi:. 

Morbid  excesses  of  development  of  the  skin  or  tissue  connected 
with  it  are  thus  named :  JVceuKS,  Clavus,  Verruca.,  Mephantiasis 
Arabum,  Scleroderma. 

NaeVTlS. — Mole.,  mother-mark.  This  is  always  congenital.  Dis- 
coloration and  elevation  of  the  part  exists,  with  abnormal  devel- 
opment of  the  capillaries  and  small  veins  of  the  skin ;  making 
a  small,  commonly  flat,  vascular  enlargement.  It  is  seldom 
more  than  an  inch  in  diameter.  Erectility  sometimes  belongs  to 
the  vessels  of  nrevus. 

Caustic,  the  ligature,  the  knife,  and  vaccination  of  the  part, 
have  all  been  employed  for  the  removal  of  such  formations.  They 
may  leave  scars  worse  than  the  mole;  the  operation  ought  to  be 
exceptional.  I  have  known  it,  when  performed  early  in  infancy, 
to  be  quite  successful. 


■548 


DISEASES    or    THE    SKIN. 


Fig.  128. 


Verruca. —  Wart.  A  hypertrophy  of  the  skin,  with  great  devel- 
opment of  the  cuticle,  upon  a  small  surface  ;  of  which  no  one  needs 
a  further  description.  Some  persons  and  families  are  especially 
liable  to  them ;  why,  we  cannot  say. 

Treatment. — Strong  nitric  acid ;  acetic  acid ;  chromic  acid ; 
caustic  potassa ;  aqua  ammonise ;  or,  in  slight  cases,  nitrate  of 
silver,  carefully  applied  only  to  the  wart,  after  paring  off  nearly 
all  the  insensitive  portion  of  it,  will  always,  at  least  after  repeti- 
tions, remove  warts. 

Clavus. — Corn.     Most  persons  are  well  acquainted  with  this, 
sort  of  localized  hypertrophy  of  the  skin  of  the  foot,  from  irritat- 
ing friction  and  intermittent  pressure.    Prevention  is  more  easy, 
by  far,  tlian  cure.     Corns  are  either  hard  or  soft ;  the  latter  may 
become  inflamed  ;  the  former  hurt  only  under  decided  pressure. 

Pare  a  hard  corn  with  a  sharp  knife  or  razor  closely,  but  not  so 
as  to  hurt  or  draw  blood.  Soak  the  foot  then  in  warm  water  for 
five  or  ten  minutes,  and  pick  out  carefully  the  centre  or  "core." 

Two  thicknesses  of  adhesive 
plaster,  with  the  centre  cut 
out  (making  a  ring),  should 
be  put  over  the  corn ;  and  a 
third  piece,  its  centre  not  cut 
out,  placed  upon  it  and  them. 
Soft  and  inflamed  corns  re- 
quire removal  of  all  pressure 
for  a  while,  and  poulticing, 
etc.,  first;  then  the  above 
treatment. 

Condylomata. — These  are 
fleshy  tumors  or  outgrowths, 
more  or  less  hard  and  wart- 
like sometimes;  in  other 
cases  soft ;  of  syphilitic  origin 
often,  but  not  always.  Espe- 
cially apt  are  they  to  occur 
about  the  anus,  prepuce,  and 
vulva. 

To  remove  such  forma- 
tions, if  they  be  small  and 
hard,  nitric  acid,  pure,  may 
be  used,  with  care  to  limit 
its  contact  to  the  part  to  be 
destroyed.  When  large  and 
soft,  if  troublesome  enough 
to  require  destruction,  the 
ligature  is  generally  pre- 
ferred. It  may  be,  with  a 
needle,  passed  through  the 
centre  of  the  mass,  and  then 
drawn  and  tied  tightly 
around  the  base. 
■Bucnemia  Tropica  of  Wilson;  "Bar- 


^./Z'^- 


Elephautiasis  Arabum. 


Elephantiasis  Arabum. 

badoes  Leg." 


T  U  B  E  R  C  U  I.  A  .  549 

Enormous  cnlarjicinciit  of  the  leg,  scrotum,  or  neck,  most  often 
met  with  in  warm  countries,  l)ut  occasionally  anywhere,  is  thus 
named.  Hard  and  nearly  innnovahle  the  parts  become  at  last. 
The  connective  tissue,  as  well  as  the  dermoid  texture  proper, 
is  greatly  hypertrophied  Impediment  to  the  return  of  surplus 
material  of  nutrition  by  the  lymphatics  is  the  probable  patho- 
genetic cause ;  the  nature  of  the  impediment  has  seldom  been 
discerned.  Dr.  Manson,'  of  Amoy,  China,  asserts  the  discovery 
of  evidence  that  the  presence  of /?7arjce  (sanguinis  hominis)  in 
large  numbers  in  the  lymphatic  trunks  is  the  cause  of  the  ob- 
struction producing  elephantiasis.  The  filarise  may,  at  the  same 
time,  not  pass  through  the  lymphatic  glands,  and  so  may  not  be 
found  in  the  blood. 

This  theory  would  seem  to  be  confirmed  by  the  fact  that 
elephantiasis  is  endemic  in  several  localities.  Saville,'^  of  the 
Society  Islands,  says  seven-eighths  of  the  population  of  those 
islands  are  affected  with  it. 

Treatment. — Ligature  of  a  large  artery  is  asserted  to  have 
ai'rested  the  growth  of  elephantiasis.''  Vanzetti  cured  a  case  by 
digital  compression  of  the  supplying  artery.*  Dr.  Olavide,^  of 
Madrid,  has  reported  two  cases,  in  which  great  diminution  fol- 
lowed the  internal  and  external  use  of  iodine.  Dr.  Mackenzie,® 
of  London,  obtained  considerable  improvement  by  the  application 
of  giim-elcistic  bandages. 

Scleroderma. — First  described  by  Curzio,  17.55.  Porty-six  cases 
only  of  this  affection  were  on  record  in  1873.'  Its  characteristic 
is,  general  hardening  of  the  skin.  It  resembles  elephantiasis 
Arabum,  except  in  being  less  localized.  Thirty-three  of  the  cases 
were  in  women,  thirteen  in  men.  Its  invasion  is  gradual,  its 
course  prolonged  for  months  or  years.  The  general  health  is  not 
always  impaired.  Seven  of  the  cases  had  a  fatal  termination. 
Hebra  divided  it  into  two  varieties ;  sklerema  atrophiciim  and 
sklerema  elevatwn;  of  which  the  former  is  always  incurable.  No 
special  indications  for  the  treatment  of  either  form  have  been 
made  out.  Armaingaud'^  has  reported  great  advantage  in  one 
case  from  the  persistent  use  of  the  continued  electric  current. 

TUBERCULA. 

Acne,  Molluscum,  TAipus,  Elephantiasis  Grcecorum,  Frambcesia, 
Keloid. 

Acne. — Tuberculous  elevations,  from  inflammation  of  the  skin 
around  sebaceous  follicles,  in  which  the  secretion  is  detained,  or 
is  of  a  morbid  character — are  called  acne.  Three  varieties  may 
include  all  those  named  by  authors,  viz.,  acne  simplex,  acne  pjus- 
tulosa,  and  acne  rosacea. 

1  British  Medical  Journal,  1880. 

2  Am.  Journal  of  Med.  "-'cienees,  Getober,  1876,  p.  .5.53. 

sCarnochan  (1856),  Stratliam,  Butcher,  and  others  have  reported  successful  opera- 
tions. Crosby  Leonard  (Brit.  Med.  Journal,  June  21,  1879),  asserts  that  40  cases  out  of 
69  have  been  cured  upon  this  principle  of  treatment. 

*  (Jazette  des  Hopitaux,  18(57. 

B  El  Sinlo  Medico,  March  9,  1873.  6  Med.  Press  and  Circular,  Oct.  13, 1880. 

1  Day,  Am.  Journal  of  Med.  Sciences,  April,  1870 ;  Irish  Hospital  Gazette,  Feb.  15, 1873. 

8  Axcbiv  Geu.  de  Med.,  June,  1879. 


550 


DISEASES    OF    THE    SKIN. 


Acne  simplex  ov  punctata  has  small  and  moderately  red,  rather 
hard  tubercles,  on  the  face  principally.  When  very  hard  and 
chronic,  it  may  be  called  acne  indurata.  Black  points  commonly 
mark  the  obstructed  follicles.  Acne  piistulosa  reaches  a  more 
mature  suppuration,  and  is  often  painful,  especially  if  upon  the 
scalp. 

Acne  rosacea  always  affects  the  face  ;  usually  in  adults  and 
most  often  in  high  livers.  A  good  deal  of  soreness  attends  the 
eruption.  First,  the  pimples  are  hard,  red,  and  small ;  as  they 
mature  they  grow  somewhat  larger  ;  finally  a  little  sanguinolent 
pus  escapes,  leaving  a  small  scab.  Rose-redness  around  the  pim- 
ples, or  patches  of  them,  has  given  rise  to  the  name.     It  is 

Fig.  129. 


A.carus  Folliculorum. 


generally  a  difiicult  disease  to  cure,  and  very  unsightly,  Not 
unfrequently  it  is  hereditary.  Tilbury  Fox  thinks  it  prevails 
most    amongst  lymphatic    persons,   and   those    predisposed   to 


Fig.  130. 


Acarus  Folliculorum. 


phthisis.  Not  unfrequently  a  small  parasite,  acarus  (or  demodex) 
folliculorum^  -^of  an  inch  in  length,  is  found,  from  one  or  two  to 
fifteen  or  twenty  together,  in  the  follicles  of  the  face  affected  by 
acne.  With  the  aid  of  a  magnifying-glass,  these  groups  of  acari 
may  sometimes  be  seen  and  turned  out  with  the  point  of  a  large 
needle. 

Treatment. — Errors  of  digestion  brought  on  by  gluttony  or 
intemperance,  or  more  moderate  imprudence,  often  cause  acne. 
They  must  be  rectified  for  its  cure.  Attention  to  the  state  of 
the  bowels,  and  to  the  action  of  the  skin  generally,  is  indispen- 
sable. Saline  cathartics  are  useful  in  plethoric  cases.  Various 
mineral  waters  are  recommended— saline  and  sulphurous  espe- 
cially. The  pustules,  when  they  mature,  should  be  carefully 
punctured  with  a  needle,  avoiding  irritating  disturbances.  Solu- 
tion of  carbonate  or  bicarbonate  of  sodium  Oj  in  Oj)  in  water 
or  flaxseed  infusion,  will  be  a  good  wash.  Sulphur,  or  sulphuret 
of  potassium,  in  lotion  or  ointment,  is  also  advised  ;  or  ointment 
or  glycerole  of  nitrate  or  amide  of  mercury  (hydrarg.  ammoniat.) 
[F.  187]. 


TUBERCULA. 


551 


Fig.  131. 


Obstinate  cases  justify  more  decided  alterative  trcatnient ;  as, 
the  application,  by  a  cotton  tip  upon  a  knitting-kueedlc,  of  a 
solution  of  corrosive  sublimate,  two 
to  five  grains  to  the  ounce  of  water 
or  alcohol,  washing  it  otf  in  a  few 
moments  ;  or,  similarly,  of  pure  Gou- 
lard's extract  (liq.  subacetat. )  of 
lead,  followed  by  spermaceti  oint- 
ment, cold  cream,  vaseline,  or  gly- 
cerin and  rose-water.  Iodide  of  sul- 
plmr  ointment  (gr.  xv.  to  xxx  in  5J 
of  lard)  is  also  much  praised.  In 
acne  indurata.,  when  very  ugly,  acid 
nitrate  of  mercury  (mercury  and 
nitric  acid  each  an  ounce)  may  be 
applied,  and,  sometimes,  l)listering 
the  face  with  cantharidal  collodion 
has  been  resorted  to.  Dr.  Caro,  of 
New  York,  prefers  burning  the  parts 
by  concentrating  the  sun's  rays  upon 
them  by  means  of  a  lens. 

Molluscum. — Acute  molluscum  is 
considered  by  many  to  be  a  some- 
what contagious  tuberculous  erup- 
tion. The  small  tumors  form  with- 
out inflammation,  increasing  slowly, 
till  they  have  almost  the  size  and 
form  of  a  currant,  but  witliout  color, 
and  nearly  flat-based  or  sessile.  They 
last  from  three  to  six  months,  either 
ulcerating  finally  and  then  shrink- 
ing away,  or  inflaming  and  slough- 
ing oft',  leaving  a  pit  or  mark.  Sev- 
eral crops  of  tubercles  may  succeed 
each  other  on  the  face  and  neck,  in 
either  adults  or  children,  but  especially  in  the  latter. 

Chronic  molluscum  is  of  still  longer  duration  ;  is  not  contagious, 
and  the  tumors  are  pedummlaied,  i.  e.,  each  has  a  stem,  in  many 
cases  at  least ;  they  also  become  larger,  and  occur  over  difterent 
parts  of  the  body.  Neither  form  of  molluscum  is  common.  It  is 
proper  to  add  that  some  authorities  do  not  admit  the  contagious- 
ness of  the  acute  variety.  Balmanno  Squire  has  asserted  the  dis- 
covery of  parasitic  spores  in  the  sebaceous  matter  of  the  tumors. 

Treatment  of  acute  molluscum  seems  not  to  be  to  any  great 
extent  available.  In  chronic  molluscum  the  tumors  may  be  cut 
ofl'  at  the  peduncle,  the  divided  point  being  then  touched  with 
lunar  caustic. 

Somewhat  analogous  to,  though  not  identical  with,  molluscum 
appear  to  be  the  cases  of  '■^fungoid  rutoneous  neoplasm''''  described 
by  Hebra,  Paget,  Coats,  and  Duhring.^  A  number  of  tumors 
sometimes  occur,  on  different  parts  of  the  body.     A  case  of  a 


Group  of  Acarus  Folliculorum. 
a,  Acarus.  b,  Hair,  c,  Its  Root. 
d,  Follicle,  e,  Glaad.  (Coi-nil 
and  Eanvier.) 


1  Archives  of  Dermatology,  October,  1878. 


552  DISEASES    OF    THE    SKIN. 

similar  kind,  with  a  single  tumor,  recurrent  at  intervals  for  sev- 
eral years,  was  under  my  care  from  1878  to  1880.  It  was  pain- 
less, but  attained  the  diameter  of  f  of  an  inch,  with,  at  last,  a 
disposition  to  superficial  ulceration.  Powder  of  iodoform  appeared 
to  be  the  most  beneficial  application  to  it. 

Lupus. — L.  exedens  and  uon-exedens,^  or  1.  superficialis,  serpi- 
ginosus,  and  devorans  (Neligan).  Lupus  superficialis  is  a  rare 
disease,  in  which,  most  often  on  the  cheek,  a  small,  soft,  slow- 
gathering  tubercle  appears,  which  in  time  scabs,  and  ulcerates 
superficially,  the  scab  and  ulcer  spreading  for  an  indefinite  time, 
and  leaving  behind  them  a  permanent  whitish  seam  or  scar. 
Irritation  may  make  the  tubercle  very  painful,  and  deepen  the 
ulcer.     It  may  last  for  years. 

Lupus  serpiginosus  exhibits  one  or  more  livid,  red,  indolent 
tumors  on  the  face,  head,  or  elsewhere,  sore,  heated,  and  itching. 
In  the  course  of  mouths  they  become  filled  with  pus,  and  suffer 
an  undermining  ulceration,  which  finally  becomes  an  open, 
unhealthy-looking  sore,  forming  upon  it  a  hard,  brown  scab. 
Creeping  from  the  edge  of  its  original  seat,  in  irregular  rings, 
the  disease  extends,  leaving  behind  it  a  depressed  cicatrix.  The 
same  part  may  be  again  reached  by  its  meandering  progress. 
This  is  a  very  chronic  affection,  it  may  be  even  of  years'  duration, 
without  injuring  the  general  health. 

Lupus  exedens  or  devorans  (noli  me  tangere,  or  rodent  ulcer)  is 
characterized  by  continuous  destructive  ulceration  of  the  skin, 
subcutaneous  connective  tissue,  muscles,  and  other  parts,  at 
length  involving  even  bones;  all  following  tubercles  "rounded 
and  dusky  red,"  on  the  nose,  cheek,  eyelid,  etc.  An  ichorous 
discharge  belongs  to  it ;  cicatrization  follows  it,  sometimes  (as  in 
the  previous  form)  to  be  again  attacked. 

Young  persons,  from  ten  to  thirty,  are  especially  liable  to 
lupus,  "its  progress  is  generally  an  affair  of  years,  and  it  causes 
less  suffering  than  its  appearance  would  lead  us  to  expect.  Scrof- 
ula certainly,  and  probably  syphilis,  predisposes  to  it.  It  is  very 
ditficult  to  cure ;  sometimes,  at  least,  incurable.  The  obvious 
alliance  with  cancer  has  induced  some  authorities  to  place  lupus 
in  a  class  of  affections  called  cancroid.  It  differs  from  cancer, 
however,  in  not  involving  the  glands,  nor  contaminating  the 
general  system.     Lupus  is  a  comparatively  rare  disease. 

Iodine  (as  in  Lugol's  solution),  cod-liver  oil,  and  iron,  inter- 
nally, are  commonly  indicated  in  the  treatment  of  lupus,  espe- 
cially the  exedens.  Fowler's  or  Donovan's  solution  may  also,  or 
each  in  its  turn,  be  cautiously  given.  Chlorate  of  potassium  has 
been  suggested  ;  I  do  not  know  of  its  trial.  Sea-bathing  is  likely 
to  assist  in  the  treatment. 

Locally,  the  animal  oil  of  Dippel  (made  by  dry  distillation  of 
hartshorn  shavings)  has  a  reputation  in  Europe  for  lupus  super- 
ficialis as  well  as  for  1.  devorans.  So  have  dilute  solutions  of 
chloride  of  zinc,  nitrate  of  silver,  nitric  acid,  etc.  In  the  super- 
ficial variety,  collodion,  softened  perhaps  by  adding  ^th  of  glyc- 

1  It  is  urged  by  Jonathan  Hutchinson,  of  London  Hospital,  that  this  distinction  is  of 
no  importance  in  classification,  as  the  difference  depends  mainly  on  the  part  of  the  body 
affected.    London  Hospital  Reports,  yoI.  iv. 


TUBEKCULA.  653 

erin,  may  be  painted  lightly  over  the  ulceration,  every  day  or 
every  few  days. 

Excision  is  sometimes  practised  for  the  exedent  form,  to  pre- 
vent disfiguration ;  but  tlie  success  of  the  operation  is  uncertain. 
So  is  that  of  strong  caustics.  Among  these,  nitrate  of  silver  is 
preferred  by  most  surgeons.  Acetate  of  zinc,  used  solid  for 
touching  the  ulcer,  and  applied  every  day  or  two,  was  much 
recommended  by  Neligan.  He  used  also  a  lotion  of  the  same 
salt,  from  three  to  five  grains  to  an  ounce  of  distilled  water,  i 
Broadbent's  treatment  for  cancer,  by  injection  of  acetic  acid, 
might  be  worth  a  fair  trial  in  lupus.  Its  theory  is  very  plaus- 
ible. Hebra  treats  lupus  by  local  caustics.  Carbolic  acid,  locally 
applied,  is  worthy  of  trial  in  this  disease  ;  and  so  is  iodoform. 

Elephantiasis  Grsecorum. — Called  by  this  name  among  the 
Greeks,  because,  as  the  elephant  is  a  great  and  powerful  animal, 
so  is  this  a  formidable  disease.  It  was  probably  the  leprosy  of 
Europe  in  the  middle  ages  ;  for  whose  treatment  many  hospitals 
were  built,  and  an  order  of  Christian  knighthood  (of  St.  Laz- 
arus) was  established.  It  was  most  prevalent  in  France  and 
England  in  the  thirteenth  century,  and  somewhat  later  in  Ger- 
many;  it  rapidly  diminished  during  the  fourteenth  centur5\^ 

It  is  characterized  by  many  round  tumors,  from  the  size  of  a 
pea  to  that  of  an  orange,  livid,  purple,  yellowish  or  brownish, 
and  soft ;  on  the  face  and  other  parts  of  the  body.  The  skin 
around  them  thickens  irregularly,  giving  a  repulsive  aspect. 
Ulceration  occurs,  deepening  even  to  the  bones ;  all  the  organic 
functions  suffer,  and  finally  the  mental  faculties  become  enfee- 
bled ;  diarrhoea,  and  perhaps  tetanus,  may  precede  death.  It  is 
hereditary,  but  probably  not  contagious. 

This  disease  is  possibly  identical  with  the  spedalsked  of  l^or- 
way,  already  named.  Wilson  believes  it  to  correspond  with  the 
leprosy  of  the  Hebrews.  Allied  to  it  are  radesyge  of  Noi'way, 
the  morphie  of  Brazil,  framboesia  (raspberry  disease),  sibbens  of 
Scotland,  and  Aleppo  evil  (button  of  Aleppo);  perhaps  also  the 
ngerengere  of  New  Zealand.  Pellagra  of  Lombardy,  Spain,  and 
France,  is  described  by  some  as  having  a  certain  resemblance  to 
it ;  but  tumors  do  not  belong  to  that  disease ;  in  which,  with  a 
general  cachexia,  the  skin  becomes  discolored  and  somewhat 
thickened,  with  arrest  of  its  normal  functional  action. 

Treatment  of  elephantiasis  and  its  allies  must  be  upon  the 
principles  laid  down  for  other  serious  cutaneous  affections;  viz., 
to  endeavor  to  restore  the  balance  of  the  general  functions^  whatever 
may  be  wrong;  whether  that  be  %  tonics,  refrigerants,  or  purga- 
tives, or  other  remedies  acting  upon  the  secretions  ;  also  improv- 
ing the  nutrition  and  repair  of  the  skin,  by  local  and  general 
alteratives.  I  am  not  acquainted  with  any  specific  remedy  for 
either  of  the  forms  of  disease  just  named.  Carnochan  reports  a 
cure  of  elephantiasis  Grsecorum  by  the  ligation  of  an  artery  (the 
carotid). 

Keloid. — {Kelis,  Kelois,  Cheloid,  Sclerema.)  This  is  very  rare. 
I  saw  one  case  of  it,  in  a  medical  college  ambidatorium,  in  1860. 

1  Liveiug;  Gulstonian  Lectures,  Lancet,  March  22,  1873. 
47 


554  DISEASES    OF    THE    SKIN. 

Wilson,  some  years  ago,  stated  that  but  twenty-four  cases  of  it 
were  upon  record ;  more  have  been  reported  upon  since.  An 
irregular,  cicatrix-like,  smooth,  reddish  and  whitish,  corrugated 
excrescence,  painful,  with  a  stinging  sensation,  sometimes,  but 
not  always ;  nearly  in  every  case  forming  upon  the  front  of  the 
chest;  slow  in  growth,  not  ulcerating,  and  not  tender  to  the 
touch.  It  is  not  unfrequently  spontaneously  removed  by  absorp- 
tion; but  has  not  been  shown  to  be  amenable  to  treatment. 
Eayer  advises  constant  firm  compression. 

Hemorrhagic;. 

Purpura  is  the  only  affection  of  the  skin  belonging  under  this 
head.  On  parts,  or  often  the  whole,  of  the  body,  appear  round 
red  spots,  which  become  gradually  of  a  dark  purple  color ;  and 
then  pass  as  bruise-marks  do,  through  green  and  yellow,  till  they 
disappear.  They  are  extravasations  of  blood  into  or  upon  the 
true  skin,  from  its  capillary  vessels.  The  duration  of  each  spot 
is  about  a  week  or  ten  days.  Actual  hemorrhage  from  the  skin 
has  been  known  to  occur  in  a  few  cases  (diapedesis,  hsemidrosis). 
Some  of  these,  however,  probably  were  rather  examples  of  hoemo- 
philia  (hemorrhagic  diathesis).  Feverishness  may  precede,  and 
prostration  may  accompany  purpura.  In  bad  cases,  hemorrhages 
may  take  XDlace  from  the  mucous  membranes,  as  of  the  mouth, 
stomach,bowels,  bladder,  vagina,  etc. ;  producing  sometimes  even 
a  fatal  result. 

Purpura  is  by  some  improperly  confounded  with  scurvy. 
Although  extravasation  of  blood  occurs  in  scorbutus,  it  may 
also  happen  quite  independently  of  it.  Deficiency  of  fresh  vege- 
table food  is  not  at  all  necessary  to  engender  purpura ;  the  causa- 
tion and  pathology  of  which,  clinical  experience  and  chemical 
investigation  have  both  failed  to  show.  In  rare  instances,  iodide 
of  potassium  has  been  known  to  produce  a  purpuric  eruption. 

Treatment.  —Although  some  assert  plethora  to  be,  as  often  as 
hydrsemia  (ansemia),  antecedent  to  purpura,  my  own  experience 
goes  with  the  ordinary  view,  that  rather  a  tonic  than  a  depletory 
treatment  is  generally  called  for  in  it.  Excessive  stimulation,  it 
is  true,  will  aggravate  its  symptoms.  Mineral  acids,  as  elixir  of 
vitriol,  and  Huxham's  tincture  of  bark,  or  quinine,  etc.,  are  much 
given.  Oil  of  turj)entine  is  also  recommended.  Neligan  pre- 
scribed it  in  large  doses ;  even  an  ounce  at  once,  with  mucilage 
and  an  aromatic.  This  is  beyond  my  degree  of  confidence  in  it ; 
but  it  is  said  that  it  generally  acts  safely  as  a  cathartic  in  such 
doses.  Ammonio-ferric  alum,  tincture  of  chloride  of  iron,  tannic 
,and  gallic  acids,  etc.,  are  used  as  styptic  medicines  in  some  cases. 
Sponging  the  body  with  alum  and  brandy  or  whisky  and  water, 
at  such  temperature  as  is  not  chilling  and  yet  is  sedative  to  the 
circulation,  will  be  the  best  local  measure.  Dr.  L.  D.  Bulkley^ 
asserts  upon  experience  that  ergot  is  the  best  remedy  for  purpura. 
He  gives  it  either  or  both  by  the  mouth  and  hypodermically  ; 
preferably  the  latter,  injecting  from  ten  to  thirty  minims  of  the 
fluid  extract  of  ergot  at  each  dose. 

IN.  Y.  Med.  Journal,  April,  1877. 


NEUROSES.  555 


NEUROSES. 

Under  this  head,  of  aficctions  involving  the  innervation  of  the 
skin,  may  be  classed  Prnrign^  Ancestliesi<(,  and  Neuralgia  cutis. 

Prurigo.— Often  placed  under  imptdm,  because  sometimes  mi- 
nute pimples  occur  with  it — the  essence  of  this  disease,  really,  is 
intense  itching  witliout  eruption.  It  is  commonly  divided  into 
prurigo  mitas,  formicans^  and  senilis.  Pruritus  is  the  technical 
name  for  itching  as  a  symptom.  Its  most  frequent  cause  is  the 
presence  of  parasites.  Dr.  K.  H.  Derby  ^  insists  that  in  true 
prurigo  there  is  always  a  disease  of  the  hair  ;  with  an  epithelial 
growth  and  serous  exudation  about  each  root-sheath  of  the  part 
affected.  Wilson  holds  to  the  essentially  neurotic  nature  of 
prurigo.  Tilbury  Fox  says  that  "  the  eruption  consists  of  certain 
papules,  altered  by  scratching,  and  accompanied  by  intense 
itching,  as 2Jrimar)/  and  essential  phenomena."^  It  appears  to 
be  more  often  seen  in  Vienna  than  in  England  or  in  this  country. 

The  difference  between  the  first  two  varieties  is  one  of  degree. 
In  the  mitis,  obstinacy  rather  than  severity  exists.  In  p.  formi- 
cans,  suffering  may  be  exti'eme,  pervading  the  body.  Heat  of  a 
fire  or  of  a  bed,  rubbing  of  the  clothes,  etc.,  may  cause  an  irrita- 
tion which  drives  the  patient  to  rub  and  tear  the  skin,  yet  without 
relief.  Sleep  may  thus  be  prevented,  and  the  bodily  as  well  as 
mental  exhaustion  so  produced  may  be  great.  The  complaint  is 
occasionally  intermittent.  Very  often  it  is  confined  to  one  or  two 
portions  of  the  body  ;  as  the  scrotum,  vulva,  anus  (pruritus  scroti, 
vulvce,  ani,  Yelpodicis),  etc.  Pruritus  ani  is  often  caused  by  worms, 
especially  ascarides  ;  sometimes  bj^  a  minute  fungous  vegetation. 
It  must  be  carefully  distinguished  from  eczema  of  the  same  parts. 

Prurigo  senilis  is  so  named  because  of  its  frequency  in  old 
people.  Lice  cause  it  not  unfrequently.  Papulge  attencl  it  more 
often  than  the  other  forms.  Tilbury  Fox,  however,  denies  its 
identity  with  true  prurigo. 

Treatment. — This  is  sometimes  a  very  hard  disease  to  cure,  or 
even  to  relieve.  We  must  consider  and  treat  the  general  con- 
dition of  the  body  ;  see  that  the  bowels  are  regular,  the  digestion 
normal,  the  skin  kept  clean  and  open  by  al)iutious  and  proper 
change  of  clothing.  Sometimes  nervine  tonics  may  be  required  ; 
as  nux  vomica,  arsenic,  or  quinine,  in  small  doses.  Tincture  of 
aconite  is  prescribed  by  some ;  three  or  four  drops  at  a  time'' 
twice  or  thrice  daily.  Conium,  belladonna,  and  other  narcotics 
have  been  advised.  The  hypodermic  injection  of  morphia  may  be 
employed  to  give  rest  in  very  distressing  cases. 

Rothmund-'  asserts  the  beneficial  influence  of  the  internal  use, 
and  also  the  hypodermic  administration,  of  solution  of  carbolic 
acid. 

Locally,  many  things  may,  and  should,  be  tried  in  succession, 
in  the  search  for  palhatives.  Baths  of  flaxseed  tea,  with  or  with- 
out carbonate  of  sodium  or  of  potassium  ;  lathering  with  castile 
soap,  with  a  shaving-brush ;  strong  salt  water,  or  whisky  and  salt ; 


iSitzungsberichte  der  k.  Akademie  dnr  Wissenschaften,  vol.  lix.,  1869. 
2 Skin  Diseases,  etc.:  '2d  American  edition,  1873. 
3  London  Med.  Record,  .Tan.  22,  1873. 


556  DISEASES    OF    THE    SKIN. 

pure  vinegar,  or  hot  water,  applied  with  a  sponge ;  dilute  sul- 
phuric, nitric,  or  acetic  acid  [F.  190,  191,  192,  193]  ;  mercurial 
ointment ;  ointment  of  creasote  [F.  224]  ;  solution  of  carbolic 
acid ;  cerate  of  white  lead ;  laudanum,  sp.  camphor,  aconite, 
or  chloroform,  as  lotion,  or  in  liniment ;  spirituous  solution  of 
corrosive  sublimate  [F.  194]  ;  solution  (dilute)  of  hydrocyanic 
acid  [F.  195]  ;  solution  of  bromide  of  potassium  ;  equal  parts  of 
chloral  hydrate  and  camphor ;  glyceramyl  j  pure  glycerin  ;  tar 
ointment  j  olive  oil ;  benzoated  vaseline  ;  ointment  of  iodoform 
(gr,  X  in  §j)  ;  equal  parts  of  chloral  and  camphor;  hypodermic 
injection  of  pilocarpin  (Simon) ;  tobacco  infusion  ;  the  "  Turkish," 
or  hot-air  bath  ;  and  the  common  hot-water  bath  :  these  are  only 
a  few  of  the  measures  which  may  be  resorted  to.  The  diet  should 
be  unstimulating.  Advice  should  be  given  to  the  patient,  also, 
to  refrain  as  much  as  possible  from  violence  in  rubbing  or  scratch- 
ing the  parts  alfected ;  and  not  to  sleep  in  a  very  warm  room 
or  under  too  much  cover.  Pruritis  ani  may  be  palliated  by  mod- 
erate dilatation  of  the  anus  ;  as  by  the  middle  finger  of  the  patient, 
or  a  bougie  of  tallow  or  cacao  butter.  Hot  water  (not  warm) 
applied  with  a  sponge,  is  often  very  relieving  to  this  symptom. 
Dr.  Bulkley  ^  gives  for  it  tincture  of  gelsemium  internally  ;  begin- 
ning with  ten-drop  doses,  and  watching  their  effects  carefully. 

Pruritus  vulvce  is  asserted  by  Friedreich  to  be  often  produced 
by  minute  fungous  organisms,  and  to  be  relieved  by  the  appli- 
cation of  parasiticides.  Dr.  A.  Wiltshire^  confirms  this  view  ; 
recommending  solutions  of  borax  (5j  tofgvor  f,^vj),  boracic  acid 
in  vaseline,  iodine  dissolved  in  elder-flower  water  (5ij  in  fgx), 
or  corrosive  sublimate  (gr.  ij  in  f^x).  Anodynes  may  be  added 
to  either  of  these  ;  as  sulphate  of  morphia  (gr.  ij  in  fgx),  atro- 
pia  (gr.  \  in  f.5x),  veratria  (gr.  \  in  fgx)  aconitia  (gr.  ^  in  fgx), 
chloroform  or  dilute  hydrocyanic  acid  (f5ss  to  fgx).  Where  the 
affection  appears  to  be  part  of  a  general  '"nervous  erethism," 
the  local  as  well  as  general  administration  of  bromide  of  potas- 
sium may  prove  beneficial.     [See  F.  364-368.] 

Ansesthesia  cutis  is  only  a  symptom  of  a  larger  affection — 
involving  either  the  nervous  system  or  the  skin  itself.  It  appears 
in  one  variety  of  elephantiasis,  called  by  some  lejjra  ancestlietica. 
Vitiligo  also  is  often  attended  by  it,  at  the  parts  which  undergo 
discoloration.  Except  stimulating  frictions,  when  not  contraindi- 
cated  by  the  other  conditions  of  the  case,  and  galvanism  (faradi- 
zation) under  the  same  limitations,  we  have  no  special  remedies 
to  mention  for  loss  of  sensibility  in  the  skin. 

Neuralgia  of  the  skin,  temporarily,  at  least,  limited  to  it, 
does  undoubtedly  occur,  though  seldom.  I  have  experienced  it 
in  my  own  person.  Its  locality  does  not,  however,  so  remove 
it  from  other  forms  of  neuralgia  as  to  require  for  it  a  special 
consideration. 

PARASITICJS.3 

Dermatologists  are  not  all  agreed  upon  the  question  whether 
the  microphytes  or  epAphytes   (minute  parasitic  vegetations)  dis- 

1 N.  Y.  Med.  Journal,  1881,  p.  30.  -  Brit.  Med.  Journal,  March  5, 1881. 

*Some  writers  have  proposed  the  common  name  of  tinea  on  phytosis,  lor  this  group. 


PARASITICA. 


557 


covered  by  aid  of  the  microscope,  in  connection  with  certain  skin 
diseases,  are  essential  to  tliose  diseases,  or  accidental  and  second- 
ary only.  Wilson  even  denies  their  vegetative  nature ;  asserting 
them  to  be  results  of  spontaneous  granular  degeneration  of  epi- 
thelium. Most  authorities  hold  the  opinion,  which  I  fully  believe 
to  be  correct  (especially  proved  by  the  results  of  treatment),  that 
the  parasites  are  really  the  essential  (xiuscs  of  the  disorders  they 
constantly  attend  ;  that  they  may,  under  favorable  circumstances, 
be  transplanted;  and  that,  to  cure  those  disorders,  destruction  of 
the  parasitic  forms  is  necessary.  Again,  Hebra,  a  high  European 
authority,  believed  that  all  the  epiphytes  described  are  merely 
modifications  of  one  and  the  same  species,  in  different  degrees  of 
development.  Tilbury  Fox  agreed  with  this  opinion.  E.  Hallier 
makes  three  series  (Mucor,  Achorion,  Leptothryx)  of  forms,  all 
capable  of  being  educed  from  the  same  spores  under  different 
circumstances.  Devergie'  believes  in  spontaneous  generation  of  the 
epiphytes,  although  truly  vegetable.  Dr.  McCall  Anderson-  gives 
proofs,  by  separate  inoculation,  of  the  non-identity  of  three  vege- 
table parasites  at  least — trichophyton^  achorion,  and  microspoi'on. 
Bazin,  T.  Fox,  and  others  have  observed  the  transmission  or 
transplantation  of  trichophyton  (tinea  carcinatus)  from  the  ox  and 
horse  to  man.-* 

No  doubt  exists  with  the  large  majority  of  observers  as  to  the 
cause  of  the  animal  parasitic  eruption,  scabies  or  itch. 

Scabies.— Chiefly  vesicular,  this  disease  may  be  papular,  scaly, 
or  pustular  in  some  instances.  Ordinarily  we  see — especially  be- 
tween the  fingers  and  on  the  back  of  the  hand,  next  often  on  the 
arms,  legs,  and  abdomen,  occasionally  on  the  scalp,  hardly  ever 
on  the  face — a  number  of  small  red 
elevations  with  white  or  watery 
tops.  Extreme  itching  is  always 
present ;  often  keeping  the  individ- 
ual scratching  night  and  day.  King 
James  I.  is  said  to  have  described 
his  experience  of  it  as  rather  pleas- 
urable ;  but  this  is  not  the  common 
account  of  it. 

Closely  looking  at  almost  any  of 
the  vesicles  one  may  see  a  little 
red  line  or  track,  at  the  end  of 
which  may  be  found  a  slightly  ele- 
vated point.  In  this  is,  generally, 
the  animalcule — Sarcoptes  hominis 
(Acarus  scabiei);  one  of  the  Arach- 
nida — flat  -  bellied ,  round  -  backed, 
tortoise-shaped,  eight-legged ;  the 
female  larger  than  the  male,  which 
is  hard  to  find. 

Treatment. — Sulphur  is  not  the 
only,  but  is  the  most  reliable  and  convenient  parasiticide  for  itch. 


Fig.  132. 


Male  Acarus.  (McCall  Anderson.) 


1  Archiv  fiir  Mikroscopische  Anatomie,  April,  1866. 

2  Brit,  and  For.  Med.-Chirurg.  Review,  July,  1866,  p.  225. 

3  British  Medical  Journal,  March  25, 1871. 


47 


558 


DISEASES    OF    THE    SKIN. 


After  thorough  bathing  and  washing  of  the  whole  body  with 
soap  and  water,  sulphur  ointment  must  be  rubbed  well  into  the 
parts  affected.  A  few  applications  will  usually  suffice  [F,  197] . 
Dr.  Tilbury  Fox  advised  a  weak  ointment — half  a  drachm  of  sul- 
phur to  an  ounce  of  lard.  The  animalcule  is  killed,  and  the  cure 
results.  There  is  evidence,  however,  that  in  some  cases  of  long 
standing,  recovery  may  follow  but  very  slowly.  The  habit  of  the 
eruption  has  then  become  established  in  the  skin ;  this  must  be 
treated  like  eczema,  or  lichen,  whiehever  it  most  resembles. 

Oil  of  turpentine,  kerosene  or  petroleum  (Decaisne),  solution 
of  sulphurous  acid,  ointment  of  sulphuric  acid,  carbolate  of 
sodium  (Zimmerman),  solution  of  chloride  of  lime,  solution  of 
corrosive  sublimate,  and  other  powerful  agents,  may  also  be 
confidently  relied  upon  to  destroy  the  itch  animalcule. 

Army-Itch.. — During  and  since  the  late  war  in  this  country, 
the  inevitable  filth  of  camp  life  begot,  among  other  evils,  a  very 
troublesome  contagious  skin-disease,  called  by  the  above  name. 
Itching,  without  any  eruption  except  small  papulae,  characterized 
it.  Outside  of  the  army  it  extended  to  a  considerable  number 
of  persons.  No  better  remedy  for  this  affection,  I  believe,  has 
been  found  than  a  lotion  and  ointment,  composed  of  iodide  of 
potassium  and  glycerin  ;  with  water  or  rose-water  for  the  lotion, 
and  lard  or  cold  cream  for  the  ointment  [F.  192, 199].  Mercu- 
rial ointment,  and  sulphuric  acid  ointment,  are  also  efficacious 
for  it. 

The  other  parasitic  affections  of  the  skin  depend  upon  the 

microphytes  already  alluded 
to.  They  are  Favus,  Bycosis^ 
Tinea  circinatus,  Tinea  decal- 
vans,  Chloasma  versicolor,  and 
Plica  Polonica. 

Favus.  —  {Porrigo,  Tinea 
Favosa.)  Generally  appear- 
ing on  the  scalp,  this  disease 
is  peculiar  in  the  formation 
of  3'^ellow  cup-shaped  crusts, 
in  each  of  wliich  one  or  two 
hairs  grow.  By  joining  to- 
gether, these  crusts  may  lose 
their  regularity  of  shape,  in  a 
general  scabbing ;  and  a  good 
deal  of  hair  may  fall  out.  A 
mealy  powder  is  found  in  the 
crusts,  which,  on  microscopic 
examination,  is  found  to  con- 
tain the  formation  called 
achorion  Schonleinii  by  Re- 
mak.i  This  presents  minute 
tortuous  branching  tubes, 
straight  or  crooked  not 
branching  tubes,  and   spor- 


FiG.  1.S3. 


Spores  and  Tubes  of  the  Microsporon  fur- 
fur, from  a  case  of  Pityriasis  versicolor. 
(McCall  Anderson.) 


1  The  achorion  was  discovered  in  favus  by  Schonlein  in  1839. 


P  A  li  A  S  I T I  C  vE .  559 

ules,  free  or  united  in  bead-like  strings.  Granules  and  cellules 
of  mi/celium^  the  generative  portion  of  the  plant,  are  abundant. 
An  offensive  dischax'ge  occurs  from  the  eruption  in  bad  cases. 

Favus  is  contagious,  though  seldom  conveyed  to  cleanly  per- 
sons. It  is  hard  to  cure,  but  not  incurable.  In  its  treatment, 
constitutional  and  local  measures  must  be  combined.  Arsenic 
is,  as  usual,  the  most  reliable  alterative.  Neligan  has  advised 
the  iodide  of  arsenic,  gr.  ^  thrice  daily;  intermitted  if  headache 
or  dryness  of  the  mouth  come  on. 

For  the  local  treatment,  the  hair  must  be  closely  cut  with  sharp 
scissors.  Apply  then  a  large  flaxseed  poultice  for  twelve  hours 
or  more — perhaps  repeatedly,  to  soften  the  crusts.  Next,  wash 
the  head  thoroughly,  by  means  of  a  soft  sponge,  with  solution  of 
carbonate  of  potassium  (one  drachm  to  a  pint  of  water);  after 
which  ointment  of  carbonate  of  potassium  (potass,  carb.  5j: 
glycerin  f3j,  adipis  gj)  may  be  applied  spread  thickly  on  lint, 
covered  with  oiled  silk.  This  may  be  renewed  daily ;  or,  if  there 
be  much  discharge,  twice  a  day.  The  crusts  will  then  come 
away  in  a  few  days.  Ointment  of  iodide  of  lead  may  follow  ; 
washing  the  head  night  and  morning,  still,  with  the  carbonate 
of  potassium  lotion  ;  and  keeping  the  hair  cropped  short  all  the 
time.  Three  or  four  weeks  will  generally  suffice  for  a  cure. 
Cleanliness  of  person  and  regulated  diet  are  at  the  same  time,  of 
course,  essential. 

For  this  and  other  parasitic  affections  of  the  skin,  tar  ointment 
is  a  far  from  contemptible  remedy. 

Sycosis  [Mentagrci). — This  occurs  in  the  bearded  part  of  the 
face,  chiefly  the  chin.  It  is  contagious  ;  sometimes  being  trans- 
mitted by  uncleanly  barbers  in  shaving.  It  presents  slightly 
inflamed  elevations  about  the  roots  of  the  hairs,  covered  by  scurf; 
shaving  decapitates  these,  inducing  irritation  and  suppuration, 
as  well  as  scabbing.  The  whole  chin  may  become  swollen  and 
inflamed  by  it ;  and  parts  of  the  beard  may  be  destroyed.  The 
parasitic  cause  of  this  disease  is  the  tricophyton  mentagrophytes 
{microsporon  mentagrophytes  of  Gruby).  It  is  seen  under  the 
microscope  to  consist  of  minute  stems,  bifurcated  at  angles  of 
from  40°  to  80°,  and  granulated  within. 

Sycosis  is  not  common,  at  least  in  America.  It  is  tolerably 
frequent  in  France.  Acne,  impetigo,  and  ecthyma  of  the  bearded 
part  of  the  face  may  be  confounded  with  it.  It  is  very  hard  to 
cure.  In  its  treatment,  keeping  the  beard  constantly  very  short 
by  close  clipping  (not  shaving)  is  essential.  Sponging  twice  daily 
with  castile  soap  and  water,  or  carbonate  of  potassium  lotion, 
will  be  beneficial.  Iodide  of  lead  ointment,  ointment  of  nitrate 
of  mercury,  and  of  calomel  and  camphor,  etc.,  may  be  used  in 
succession  ;  besides  the  internal  use  of  arsenic. 

Tinea  circinata  {Bingworm,  Scald  Head). — This  is  known  by 
its  circular  form,  occurring  most  often,  though  far  from  always, 
on  the  head  or  face.  Herpes  circinatus  resembles  it ;  but,  in  that, 
minute  vesicles  are  usual ;  in  tinea,  rare  and  few.  In  tinea  a  thin 
powdery  crust  exists,  whose  examination  will  show  the  tricJio^ihy- 
ton  tonsurans,  closely  allied  to  the  parasite  of  sycosis. 

Tinea  decalvans  (or  tonsurans)  is  marked  by  the  destruction  of 


560 


DISEASES    OF    THE    SKIN, 


Fig.  134. 


the  hair  in  circular  patches,  making  round  si^ots  of  baldness.  Its 
parasite  is  considered  by  many  dermatologists  as  different  from 
the  trichophyton,  ?iiid  called  microsporon  Audouinii,  Its  sporules 
are  rounder  and  smaller  than  those  of  the  trichophyton.^ 

The  treatment  of  both  forms  of  tinea  must  be,  besides  cleans- 
ing, essentieAly  parasiticide.  Tar  ointment;  " huile  de  cade  ; " 
mercurial  ointment ;  solution  of  corrosive  sublimate  ;  oleate  of 
mercury;  lotion  and  ointment  of  carbonate 
of  potassium  ;  lotion,  of  sulphurous  acid  ;  car- 
bolic acid  ;  creasote  ;  ointment  of  crysophanic 
acid  ;  pyrogallic  acid  lotion ;'-  solution  of  boracic 
acid,  5j  in  Sj  '■>  cantharidal  collodion,  lightly 
applied  ;  these  are  among  the  many  applica- 
tions which  may  be  used  for  the  purpose,  with 
generally  successful  results. 

As  has  been  observed,  tinea  is  seldom 
transmitted  to  a  cleanly  person  ;  at  least  with- 
out very  close  and  continued  contact. 

Chloasma    Versicolor    {Pityriasis    Versi- 
color).—The  parasite  of  this  is  raicrosporon 
furfur.     The  disease  is  recognized  by  the  for- 
mation of  dull,  reddish-yellow  spots  of  various 
size  and  shape,  seldom  numerous,  on  the  front 
of  the  chest   or  abdomen.      The   same  local 
applications  may  be  used  for  it  as  for  tinea  ; 
besides  the  internal  use  of  arsenic. 
Plica  Polonica. — This    is  an  affection  of 
Y'fStWPBHP'P         ^^®  hairy  scalp,  endemic  in  Poland,  Russia, 
iS^Si^B'         and  Tartary.     The  hair-follicles  become  dis- 
eased,   and   the  hair  is   matted   and    glued 
together  into  felt-like  masses.     TrichopJiyton 
Tin  ea^Tonsura'^s  ^'^"^^''''^"■^  ^nd  trichophyton  sporuloides  are  the 
loaded  with  spores,  parasitic  vegetations  described  as  found  con- 
(McCallAuderson.)  nected  with  it.    The  disease  has  not  been  seen 
in  this  country.     Some  dermatologists  assert 
that  it  is  nothing  but  eczema  capitis,  with  seborrhoea  and  dirt ; 
but  this  is  not  probable. 

SYPHILIDA. 

Enough  for  our  purpose  and  space  has  already  been  said  of  the 
general  history  of  syphilis.  Among  its  constitutional  manifesta- 
tions cutaneous  eruptions  are  very  frequent.  These  are  seldom 
vesicular,  not  very  often  papular  ;  most  often  squamous  or  scab- 
bing. Lepra  and  rupia,  particularly  the  latter,  are  prominent 
among  syphilitic  affections,  though  both  may  occur  independently 
of  syphilis.  All  eruptions  in  persons  of  this  diathesis  are  marked 
by  a  coppery  color,  which  remains  long,  even  after  their  cure  ;  by 
a  disposition  to  ulcerate,  perhaps  only  superficially;  and  by  pref- 
erence in  locality  for  the  face,  shoulders,  and  back. 

In  the  treatment  of  syphilitic  eruptions,  the  diathesis  must  be 

1  Duhring  includes  tinea  eircinata  and  Hnea  tonsurans  together,  as  tinea  tnchophytina. 

2  Blention  has  been  made  on  a  previous  page  to  the  propriety  of  caution  in  the  use 
of  chrysophanic  and  pyrogallic  acids.    (See  Psoriasis.) 


Hairs  from  a  case  of 


FKOST-BITE;   CHILBLAIN.  561 

met  by  our  remedies.  Iodide  of  mercury  internally;  after  that, 
iodide  of  potassium,  and,  in  feeble  persons,  cod-liver  oil,  perhaps 
iodide  of  iron  ;  locally,  menuirial  ointment  (besides  palliatives,  if 
required,  as  in  other  eruptions)  or  the  calomel  vapor  bath  should 
be  prescribed.  Often  such  afl'ections  will  seem  to  be  cured,  but, 
after  weeks  or  months,  will  retui'n  again  ;  then  the  treatment 
should  be  renewed,  and  discontinued  when  they  disappear. 

POISON-VINE  ERUPTION. 

The  common  poison-vine^  [Bhiis  toxicodendron),  a  species  of 
swamp  sumach,  and  one  or  two  other  plants  more  rarely,  cause, 
by  contact,  in  some  persons,  an  inflamed  vesicular  eruption  of 
considerable  severity.  The  hands  and  face  are  its  most  common 
localities ;  but  it  may  come  out  on  the  lower  limbs  or  about  the 
anus  and  genitals.  Its  duration,  when  severe,  may  be  from  one 
to  two  weeks ;  but  it  is  often  quite  limited  and  of  short  course. 

In  the  treatment  of  this  annoying  but  not  dangerous  attack,  I 
have  had  a  good  deal  of  experience  in  my  own  person  as  well  as 
with  others.  I  have  found  much  relief,  and  great  effect  in  short- 
ening the  course  of  the  disease  by  reducing  the  inflammation,  from 
Icad-water.earh/,  freely,  and  frequently  applied  with  a  large  camel's- 
hair  pencil.  It  should  not  be  put  upon  the  openecZ  vesicles,  which 
it  irritates ;  but  around  them,  upon  the  reddened  skin.  In  the 
practice  of  Dr.  E.  Hartshorne,  a  successful  remedy  has  been  the 
fluid  extract  of  serpentaria,  painted  directly  upon  the  erupti(m. 
It  seems  to  kill  it  at  once.  Oxide  of  ziuc  ointment  is  sometimes 
very  soothing  to  the  eruption.  Dr.  Hatch, '^  of  California,  finds 
solution  of  sulphate  of  iron  beneficial  in  this  affection.  Late 
experience  with  it  (1874)  has  convinced  me  that  the  bicarbonate 
of  sodium.,  in  strong  solution,  applied  early  with  a  camel's-hair 
pencil,  is  especially  efficacious.  Its  action  (and  that  of  lime- 
water,  also  sometimes  useful)  is  explained  by  the  fact,  pointed 
out  by  Prof.  Maisch,  of  Philadelphia,  that  the  active  principle 
of  the  poison-vine  is  an  a.cid—toxicodcndric  acid.  Dr,  Brandt,' 
of  Indiana,  recommends  a  saturated  solution  oi  sulphite  of  sodium, 
constantly  applied,  Dr,  Brown,'*  U.  S,  N.,  asserts  that  bromine 
exercises  a  specific  control  over  rhus  poisoning.  He  dissolves 
bromine  in  olive  oil  or  vaseline,  10  or  20  drops  to  the  ounce,  rubs 
this  gently  over  the  parts  aftected  three  or  four  times  a  day,  and 
washes  the  parts  afterwards  with  soap.  Lathering  the  seat  of 
the  eruption,  with  a  soft  shaving-brush,  is  very  relieving  to  the 
itching  and  burning  which  attend  it, 

FROST-BITE;  CHILBLAIN. 

Gangrenous  destruction  of  parts,  especially  of  toes,  not  unfre- 
quently  follows  actual  congelation.     Short  of  this,  exposure  to 

1  This  somewhat  resembles  the  Virginia  Creeper,  but  is  three-leaved.  One  variety  of  it 
is  erect,  not  climbinfc. 

-  California  Med.  Gazette,  1869 ;  also  Butler  &  Brinton's  Half-yearly  Compendium, 
part  iv.,  p.  1.12. 

3  N.  Y.  Medical  Record,  July  12,  1879.  p.  46.  Dr.  Ward  (same  Journal,  Aug.  21,  1879), 
advises  liquor  sotlce  c/ilorina/re  diluted  with  from  3  to  6  parts  of  water. 

*  Boston  Med.  and  Surgical  Journal,  1879. 

2L 


562  UNCLASSIFIED    AFFECTIONS. 

continued  cold,  especially  when  suddenly  warmed  again,  may 
cause  an  erythematous  inflammation,  erythema  pernio,  already 
mentioned  under  that  head.  When  the  feet  or  other  parts  have 
been  so  chilled  as  to  be  almost  frozen,  gradual  warming — for  in- 
stance, at  first  rubbing  them  with  snow — is  proper  as  a  preventive 
of  frosting.  In  its  treatment,  cooling  unguents,  as  Goulard's 
cerate,  or  lotions,  as  lead-water,  may  be  first  indicated,  and 
then  astringents,  as  alum-water,  infusion  of  oak-bark,  solution 
of  chloride  of  iron,  creasote  ointment,  etc.  Cabbage  leaves  are 
a  popular  domestic  remedy  for  chilblains. 

BURNS  AND   SCALDS. 

If  half  of  the  body  be  so  burned  or  scalded  as  to  arrest  the 
functions  of  the  skin  over  that  extent  of  surface,  death  will  always 
result.  Collapse  comes  on  from  the  terrible  shock  to  the  nervous 
system  through  the  impression  on  the  widely  distributed  cutane- 
ous nerves.  The  pulse  is  then  very  low,  the  body  cold,  and,  com- 
monly, thirst  is  great.  Sufiering  is  often,  in  a  few  hours,  lost  in 
apathy  and  prostration. 

The  treatment  for  this  prostrated  condition  must  be  stimu- 
lant as  well  as  anodyne.  Opium  and  whisky,  or  wine,  should  be 
given  as  freely  as  in  any  other  condition  of  positive  debility  or 
exhaustion. 

For  local  treatment  of  burns,  I  believe  that  nothing  is  better 
than  lime-water  and  cdl,  equal  parts  (either  linseed,  olive,  or  lard 
oil),  on  cotton  wadding,  covered  with  oiled  silk.  Other  remedies 
often  used  are,  dry  cotton  (which  sticks  too  close  in  deep  burns], 
glycerin,  rye-meal,  starch  powder,  fresh  lard,  fruit  jellies  (Marin), 
carbolic  acid,^  and  molasses.  To  exclude  the  air  seems  to  be  the 
main  indication.  I  have  been  disappointed  in  several  trials  of 
a  saturated  solution  of  sodium  bicarbonate,  which  was  much 
praised  as  a  remedy  for  burns  a  few  years  ago.  Soap-suds  will 
do  as  much  or  more  good. 

UNCLASSIFIED    AFFECTIONS. 

AMENOREHCEA. 

A  few  words  seem  appropriate  here  u^ion  some  of  those  affec- 
tions of  the  sexual  system  which  every  practitioner  must  often 
meet  with.  Their  full  discussion  belongs  to  books  of  a  different 
kind.  Especially  at  a  distance  from  the  large  cities,  a  general 
practitioner  will  often  have  occasion  to  make  his  own  diagnosis 
in  such  cases,  and,  perhaps,  carry  out  his  own  treatment.  In 
regard  to  the  more  serious  operations  of  gynaecological  surgery, 
much  caution  may  very  reasonably  be  exercised  by  any  one 
whose  opportunities  have  not  enabled  him  to  acquire  the  skill  of 
the  specialist.  Upon  these  subjects,  the  works  of  Thomas,  Barnes, 
Atlee,  and  Emmet  may  be  especially  recommended  for  study  and 
reference. 

1  In  solution,  3lj  in  O.j  of  water ;  ov  1  part  to  7  parts  of  glycerin ;  or  else  Lister's 
"carbolic  oil,"  1  ounce  of  carbolic  acid  in  a  pint  of  olive  or  linseed  oil;  or  carbolized 
oxide  of  zinc  oiutmeut,  1  part  carbolic  acid  to  32  parts  zinc  ointment. 


AM  EN  oil  KIKE  A.  563 

Amenorrhoea,  or  suppression  of  iho  menstrual  discharge  in 
women,  n\ay  be  either  an  interruption  of  it  during  its  cjccurrence, 
or  its  lia1)itual  non-appearance.  The  former  is  commonly  the  result 
of  cold  and  wet,  or  of  some  nervous  shock,  to  which  the  patient 
is  exi)osed  during  the  menstrual  period. 

Habitual  amenon-ha^a  may  occur  with  plethora,  from  disturb- 
ance of  ovarian  and  uterine  functions,  or  with  ancemia  and  de- 
bility, or  as  a  secondary  effect  of  chronic  disease,  e.  {/.,  phthisis. 
The  greater  number  of  cases  is  met  with  in  ansemic  females;  but 
the  opposite  state  is  not  very  uncommon.  Vicarious  hemorrhages 
from  the  lungs,  stomach,  etc.,  sometimes  accompany  it. 

As  bearing  upon  the  treatment  of  amenorrhoea,  the  question 
always  comes  up,  is  the  suppression  of  the  menstrual  flow  the 
cause  of  other  symptoms  or  morbid  effects,  or  is  the  amenorrhea 
itself  the  effa-t  of  a  morbid  condition,  the  removal  of  which  will 
restore  this  arrested  function?  It  is  to  be  said  in  reply,  that 
sometimes  the  one  and  sometimes  the  other  may  be  the  case. 
In  amenorrho'a  with  plethora,  generally  the  interruption  of  men- 
struation may  be  found  to  be  a  primary,  though  perhaps  not  the 
sole,  cause  of  disturbance  of  the  system.  In  anaemic  amenor- 
rhoea, most  frequently  the  constitutional  state  is  primary,  and 
the  restoration  of  general  strength  will  be  attended  by  the  spon- 
taneous return  of  the  function. 

Practically,  then,  we  must,  in  any  case,  inquire  into  the  gen- 
eral condition  and  history  of  the  patient.  If  there  is  headache, 
increased  by  stooping,  with  a  flushed  face  and  full,  strong  pulse, 
the  patient  having  previously  been  vigorous  in  health,  taking 
blood  from  the  lumbar  region  by  cups,  or,  in  clear  cases,  from 
a  vein  in  the  arm  by  the  lancet,  is  indicated.  Also  purgatives ; 
at  first,  in  a  sudden  attack,  senna,  or,  if  much  heat  of  the  system 
exist,  citrate  or  sulphate  of  magnesium ;  afterwards,  when  the 
amenorrhoea  is  obstinate,  aloes.  Hot  mustard  foot-baths,  or  warm 
hip-baths,  and  warm  poultices  to  the  breasts,  every  night,  should 
be  used  in  a  case  of  sudden  suppression  of  menstruation  in  the 
midst  of  its  period.  Tincture  of  aloes  and  myrrh  is  a  favorite 
domestic  emmenagogue  ;  a  teaspoonful  twice  or  thrice  daily,  in 
hot  water.  Tincture  of  rhubarb  and  senna  (Warner's  cordial) 
will,  I  believe,  answer  as  well.  Black  hellebore,  savin,  senega, 
etc.,  are  also  resorted  to  for  similar  action ;  but  all  emmenagogues 
are  more  uncertain  even  than  diuretics. 

In  many  cases  of  amenorrhoea,  a  delicate  and,  in  some,  a  diffi- 
cult question  is,  as  to  the  possibilit}^  of  the  (physiologically)  nor- 
mal cause  of  pregnancy  being  present  to  account  for  it.  Most 
of  all  may  this  difficulty  present,  of  course,  in  young  single  women, 
who  may,  unfortunately,  have  reason  for  concealment.  Apart 
from  the  very  clear  ethical  principle  that  a  physician  has  no  moral 
right  to  aid,  in  any  way  whatever,  in  producing  an  abortion,  active 
emmenagogue  treatment  in  the  pregnant  state  is  unsafe  for  the 
healtli  of  the  subject  of  it  herself.  Medicine  will  fail  to  cause  abor- 
tion in  eight  or  nine  cases  in  ten,  unless  it  be  so  used  as  to  produce 
a  serious,  often  dangerous,  effect  upon  the  system  of  the  patient. 

When  we  susjjcct  pregnancy,  then,  mild  measures  only  are  in 
place — waiting  for  time  to  develop  the  nature  of  the  case  in  full. 


564  UNCLASSIFIED    DISEASES. 

Anceniic  amenorrhoea  requires  tonics;  above  all,  iron.  Other 
medicinal  and  hygienic  roborant  agencies  may  also  be  called  in. 
Aloes,  in  small  doses,  repeated  daily  [F.  201,  202],  occasional  or 
periodical  hip-baths,  foot-baths,  a,nd  breast-poultices,  especially 
near  the  time  when  the  menstrual  flow  should  occur — may  in 
many  cases  be  superadded.  Strychnia,  in  one-thirtieth  of  a 
grain  doses,  is  a  favorite  tonic  in  amenorrhoea  with  some  practi- 
tioners. Galvanism,  or  statical  electricity  (of  the  friction-machine) 
is  much  resorted  to  by  others.  The  spinal  and  pelvic  regions 
should  be  the  seats  of  application. 

DYSMENORRHtEA. 

Painful  menstruation  is  habitual  with  some  women  for  years 
together.  Pregnancy  not  unfrequently  cures  the  habit.  The 
affection  seems  to  be  of  two  kinds  or  origins :  1,  functional  or 
physiological,  and  2,  mechanical  dysmenorrhea.  With  the 
former,  disorder  of  innervation  and  circulation  occurs  ;  even  the 
ovaries  may  participate  in  this.  Some  women  suffer  attacks  of 
monthly  ovarian  irritation  (ovarian  colic),  with  fever.  Ordina- 
rily, before  menstruation  begins,  the  subject  of  functional  dys- 
menorrhoea  feels  ill,  with  pain  in  the  back,  perhaps  headache,  ' 
followed  by  pains,  almost  like  labor-pains  of  the  first  stage,  in  the 
womb.  That  organ  becomes  palpably  swollen  and  heavy,  its  pain 
being  somewhat  assuaged  by  compression  by  the  hand  through 
the  abdominal  wall.  When  free  discharge  comes  on,  relief  is 
obtained.  Sometimes  a  membranous  cast,  in  one  or  more  frag- 
ments, of  the  lining  of  the  uterus,  is  expelled  :  constituting  mem- 
branous dysmenorrhoza. 

The  symptoms  of  mechanical  dysmenorrhoea  are  not  always 
strikingly  different,  but  it  is  a  more  local  affection.  The  direct 
cause  of  it  is  obstruction  at  the  os  or  cervix  uteri ;  the  external  or 
internal  os  usually,  if  constriction  be  the  trouble ;  in  the  neck, 
when  anteversion,  retroversion,  or  lateral  flexion  produces  it.  On 
the  indication  of  this  causation.  Dr.  Simpson,  of  Edinburgh,  some 
years  since  introduced  the  practice  of  dilatation  of  the  os  and 
cervix  for  the  cure  not  only  of  dysmenorrhoea,  but  of  sterility, 
dependent  upon  the  same  obstruction.  A  sponge-tent  was  used 
[F.  232]  ;  sometimes,  more  lately,  the  sea-tangle  (laminaria 
digitata)  instead.  Dr.  W.  L.  Atlee  (1861)  introduced  a  uterine 
dilator,^  which  has  been  found  to  act  well  in  many  cases.  Dr. 
Ellwood  Wilson  and  Dr.  Molesworth  have  made  large  use  of 
similar  instruments.  Simpson  and  others,  however,  have  pre- 
ferred incising  the  neck  of  the  uterus  with  a  hysterotome.  Much 
discussion  on  this  subject  has  transpired.  I  must  refer  upon  it 
to  works  on  special  surgery  and  gynaecology ;  particularly  the 
works  of  Drs.  Marion  Sims  and  T.  A.  Emmet.  It  is  observable, 
however,  that  Dr.  H.  B.  Storer,  the  distinguished  obstetrician 
of  Boston,  adheres  to  careful  dilatation  instead  of  incision.  Drs. 
Tilt  and  H.  Bennet,  of  London,  and  Drs.  F.  Barker  and  Emmet, 
of  New  York,  also  object  to  frequent  hysterotomy. 

Whatever  the  cause  of  dysmenorrhoea  in  any  case,  the  subject 

1  Amer.  Journal  of  Med.  Sciences,  April,  1871. 


MENORRHAGIA.  565 

of  it  should  always  avoid  being  much  on  her  feet  for  a  day  or  two 
before  her  monthly  time ;  and  should  go  to  bed  when  the  pain 
begins.  Cloths  wrung  out  of  hot  water,  or  spirits  and  hot  water, 
may  be  placed  upon  the  aljdomen,  and  renewed  as  they  cool. 
Internally,  spirits  of  camphor,  with  compound  spirit  of  lavender 
and  hot  water  (sweetened  to  taste)  may  bo  given  [F.  203]  ;  or  if 
not  relieved,  paregoric  in  teaspoonful  doses.  Dr.  Emmet  advises 
large  vaginal  injections  of  liot  water.  Dr.  Blackwood,'  of  Phila- 
delphia, has  found  electricity  to  give  the  best  results.  The  ad- 
vantage of  avoiding  much  exercise  or  fatigue  just  before  the  time 
of  the  expected  menses  ought  to  be  impressed  upon  the  patient. 
No  medicine  appears  to  have  any  important  pro^jhylactic  effect; 
unless  it  be  iron  in  ansKmic  patients. 

MENOKEHAGIA. 

Excessive  menstruation  may  be  of  two  kinds  :  1,  its  occurrence 
too  often  ;  2,  too  great  an  amount  or  continuance  of  the  discharge. 
Both  very  frequently  occur  together.  Causes  of  menorrhagia  are 
— general  relaxation  of  system ;  over-excitement  of  the  genital 
apparatus ;  thinness  of  the  blood,  hemorrhagic  diathesis ;  and 
over-fatigue,  especially  on  the  feet,  promoting  a  descent  of  blood 
toward  the  pelvic  organs  about  the  time  of  menstruation.  Ulcer- 
ation, cancer,  or  tumors  of  the  uterus,  as  well  as  abortion  and 
placenta  prcevia,  cause  uterine  hemorrhage,  not  properly  to  be 
called  menorrhagia ;  but  metrorrhagia. 

This  affection  is  much  most  common  in  the  ansemic.  Rest, 
iron,  good  diet,  and  astringents,  internally  and  sometimes  locally, 
are  then  the  remedies  for  it.  Tincture  of  chloride  of  iron  is,  liere, 
the  favorite  chalybeate.  It  may  be  given  through  the  interval. 
During  the  attack,  ammonio-ferric  alum,  in  tive-grain  doses,  may 
be  administered  ;  or  tannic  or  gallic  acid,  three  to  five  grains 
several  times  daily.  The  indiscriminate-  use  of  iron,  however, 
simply  because  of  excessive  menstrual  discharge,  is  to  be  avoided. 
Sometimes,  without  ancemia,  the  disorder  is  due  to  uterine  con- 
gestion ;  and  then,  by  promoting  this,  iron  may  increase  the  flow. 
For  metrorrhagia,  ergot  may  be  required;  f5ss  of  the  fluid 
extract,  or  fpj  of  the  wine  every  half-hour  for  several  doses  ;  or 
hypodermic  injection  of  ergotin,  two  or  three  grains  at  once,  or 
7j-JiT  of  a  grain  of  atropia  (Tacke).  The  patient  must  be  kept 
still  upon  her  back  till  the  flow  is  controlled.  Sometimes  cold 
wet  cloths  (for  a  serious  hemorrhage)  have  to  be  put  upon  the 
abdomen ;  or  an  ice-water  sponge,  or  half  a  lemon,  or  a  syringe- 
ful  of  vinegar,  or  tannic  acid  solution,  or  of  solution  of  tinct. 
ferri  chlorid.  (foss  in  fgviij)  may  be  thrown  into  the  vagina.  Dr. 
Wooster,  of  California,  uses  injections  of  a  solution  of  chromic  acid; 
15  grains  in  f5i  of  hot  water,  passed  through  a  gum  catheter,  car- 
ried up  to  the  fundus.^  Hot  water  alone"  is  much  employed  in 
recent  practice.  It  should  be  at  a  temperature  not  below  110°  nor 
above  120°  Fahr.  Dr.  Matthews  Duncan-^  injects  tincture  of  iodine 

1  Phila.  Med.  Times,  Oct.  9,  1880. 

2  Dr.  Emmet  credits  Dr.  Sims  with  the  introduction  of  chromic  acid  as  a  local  remedy 
in  uterine  diseases.    Its  use  requires  caution. 

3  Med.  Times  and  Gazette,  August  7, 1S80. 

48 


566  UNCLASSIFIED    DISEASES. 

into  the  uterus  for  threatening  hemorrhage  ;  regarding  it  as  safer 
than  tincture  of  the  chloride  of  iron.  Dr.  Barnes  advises  that, 
at  the  time  of  an  injection  into  the  uterus,  an  assistant  should 
grasp  that  organ  through  the  abdomen,  to  lessen  the  danger  of  the 
escape  of  the  fluid  through  the  Fallopian  tubes.  Plugging,  with  a 
tampon  of  cotton,  lint,  or  sponge,^  in  a  few  instances  may  have  to 
be  resorted  to.  Dr.  T.  G.  Thomas  prefers,  for  the  application  of  a 
tampon  in  uterine  hemorrhage,  the  preliminary  distension  of  the 
vagina  with  Sims's  duck-bill  speculum.  "Pieces  of  cotton  soaked 
in  water,  pressed  and  flattened  out  by  the  fingers,  each  about  the 
size  of  a  very  small  biscuit,  may  be  pressed  into  the  vaginal  cul- 
de-sac  by  means  of  forceps  till  this  is  filled.  Then  other  pieces 
are  packed  firmly  around  the  cervix  until  only  the  os  is  visible  ; 
a  smaller  pad  is  then  pressed  firmly  against  or  introduced  within 
the  cervical  canal  and  the  whole  vagina  is  then  filled  to  its  lowest 
portion."  In  every  case  of  severe  or  protracted  menorrhagia, 
the  practitioner  must  endeavor  to  be  sure  whether  or  not  any 
malignant  or  other  organic  affection  of  the  uterus  is  present. 

LETJCORRHCEA. 

Synonyms. — Fluor  Alhus;  the  Whites.  This  is  quite  a  common 
trouble  of  women.  The  mucous  discharge  may  be  either  from 
the  vagina,  from  the  cervix,  or  from  the  uterine  cavity.  When 
from  the  glands  of  the  neck  of  the  uterus,  it  is  apt  to  be  glairy, 
like  the  white  of  an  egg.  Irritation  of  the  organs,  followed  by 
relaxation,  is  its  general  cause ;  but,  often,  relaxation  alone 
seems  capable  of  producing  it.  Procidentia  or  prolapsus  uteri 
is  a  frequent  source  of  it ;  the  descended  uterus  pressing  upon 
the  vaginal  walls,  causing  morbid  increase  of  secretion  and 
exhalation  from  one  or  both. 

In  treatment  of  leucorrhoea,  tonics  are  often  required ;  iron, 
bitters,  etc.  Also  astringents,  by  the  mouth  and  locally ;  those 
mentioned  for  menorrhagia  will  apply  here  also,  but  usually  in 
less  strength,  for  a  longer  time  [F.  204,  205].  Vaginal,  or  in 
some  cases  uterine,  suppositories  also  may  be  used.  They  may 
be  made  of  cacao  butter,  or  gelatin  and  glycerin,  medicated 
according  to  each  case.  A  suppository  for  the  uterus  should  be 
cylindrical,  of  about  the  diameter  of  a  goose-quill,  two  inches 
long,  and  weighing  about  fifteen  grains.  For  the  vagina,  of 
course,  it  must  be  larger.  If  prolapsus  or  procidentia  exist,  a 
well-adapted  pessary  (gutta  percha  or  India-rubber  ring,  or  double 
horseshoe  of  similar  light  material),  will,  in  a  majority  of  cases, 
do  good  service. 

IRSITABLE  TJTEKUS. 

This  consists  of  a  permanent  and  painful  sensibility  of  the 
womb,  especially  of  its  neck ;  often  accompanied  by  increased 
frequency  of  pulse,  a  drj^,  hot  skin,  and  generally,  in  protracted 
cases,  gastric  and  renal  derangement.  This  disease  comnionly 
occurs  in  the  middle  period  of  life,  though  it  is  sometimes  met 
with  in  early  youth. 

1  Dr.  T.  E.  Beesley  contrived  a  light  metallic  conical  plug  or  cork  for  the  vagina;  to 
be  kept  in  place  by  a  bandage.    Gutta-percha  might  be  adapted  to  the  same  purpose. 


TRRITART.E     UTRRUS.  667 

The  local  syniploins  are  pain  in  the  lumbar  and  sacral  r(!f;;ion3 
extending  down  tlie  tluLjli  ti)  Uic  knee,  and  around  the  brim  of 
the  pelvis  to  the  lowest  part  of  the  abdomen.  Tiiere  are  also 
some  erratic  pains  in  the  thorax  and  loins.  The  character  of 
the  pain  is  that  of  soreness ;  slight  pressure  relieves  it,  but  it  is 
agjgravatcd  by  rough  handling ;  sometimes  it  is  spasmodic,  like 
that  of  abortion. 

The  pain  is  incu-eased  by  excitement  of  any  kind,  by  exercise, 
and  sometimes  by  standing.  Straining,  either  in  defecation  or 
urination,  constipation,  flatulence,  and  diarrhoea  will  aggravate  it. 

A  vaginal  examination  may  prove  the  uterus  to  be  either 
displaced  or  engorged,  but  not  altered  in  form,  size,  or  density ; 
extremely  painful  to  the  touch  in  the  body  as  well  as  in  the 
neck. 

Causes. — Among  the  predisposing  causes  may  be  placed,  inju- 
dicious education,  fashionable  life,  prolonged  lactation,  and  tem- 
perament. Among  the  exciting  causes,  bodily  exertion  dm-ing 
menstruation,  astringent  injections,  abortions,  displacements, 
and  sudden  arrest  of  the  menses  in  any  way. 

Diagnosis. — From  neuralgic  dysmenorrhcea,  by  the  constancy 
of  the  pain.  From  acute  inflammation  of  the  cervix,  by  the 
absence  of  heat,  swelling,  and  throbbing;  by  the  absence  also  of 
discharges,  and  by  the  slight  changes  of  the  cervix  compared 
with  the  amount  of  suffering. 

Pathology. — Gooch  considers  it  a  permanently  painful  con- 
dition of  the  uterus,  neither  accompanied  by  nor  tending  to 
produce  change  in  structure.  Ashwell  regards  it  as  a  modified 
inflammation,  or,  at  least,  closely  allied  to  inflammation  or  con- 
gestion. Thomas  names  it  "areolar  hyperplasia,"  on  account 
of  the  increased  formation  of  areolar  or  connective  tissue  com- 
monly occurring  in  its  course.  This  term  omits,  however,  the 
recognition  of  the  "irritability"  which  gave  occasion  for  the 
name  preferred  for  this  affection  by  Hodge  and  others. 

Treatment. — Two  indications  present  themselves,  viz.:  1.  To 
mitigate  local  suftering ;  2.  To  sustain  and  improve  the  general 
health.  The  first  indication  will  be  fulfilled  by  the  use  of  ano- 
dynes, either  by  the  mouth  or  rectum,  or  applied  directly  to  the 
uterus  itself;  by  the  ai)plication  of  the  nitrate  of  silver,  and  by 
anointing  the  cervix  with  anodyne  unguents.  The  second  indi- 
cation, by  rest,  exercise  in  a  recumlDent  posture,  or,  in  some 
cases,  on  foot  or  horseback ;  tonics,  nutritious  food,  cold  bath  or 
the  douche,  and  cheerful  society.  Scarifications  of  the  neck  of 
the  uterus  are  highly  recommended  by  some  authors,  especially 
when  there  is  congestion.  The  introduction  of  a  pessary  is  often 
followed  by  marked  relief,  if  there  be  any  descent  of  the  womb. 
Dr.  T.  H.  Buckler,  of  Baltimore,  asserts  advantage  from  dilata- 
tion of  the  cervix  uteri  by  insertion  of  a  male  urethral  bougie,  left 
in  for  a  number  of  hours  at  a  time.  This  practice  is  founded 
upon  the  view  that  the  cervical  congestion  and  hyperplasia  are 
owing  to  a  strangulation  of  the  veins  of  the  uterus  by  an  exces- 
sive action  of  its  circular  muscular  fibres.  It  must  certainly 
require  care  to  avoid  the  eftects  of  direct  local  irritation,  en- 
dangering inflammation  (endometritis). 


568 


UNCLASSIFIED    DISEASES. 


Fig.  135. 


In  regard  to  pessaries,  nearly  all  the  best  gynsecologists  agree 

that  they  are  often  useful  in  sup- 
porting a  prolapsed  or  displaced 
uterus.  Hodge's  horseshoe  pess- 
ary (of  light  material)  is  frequently 
serviceable ;  and  so  is  a  simple 
India-rubber  ring  pessary.  The 
tact  of  the  practitioner,  as  well  as 
his  knowledge  of  pelvic  anatomy, 
must  be  exercised  in  selecting  and 
adapting  such  an  instrument  for 
each  case.  Dr.  M.  A.  Fallen^  pre- 
fers a  soft-day  pessary  or  "utero- 
vaginal rest." 

It  is  impossible  for  an  external 
application  of  any  kind  to  replace 
a  dislocated  womb ;  yet  there  are 
not  a  few  cases  in  which  the  real  origin  of  the  trouble  is  relaxation 
of  the  muscular  parietes  of  the  abdomen,  and  consequent  tendency 
to  descent  of  all  of  its  contents.  For  this  state  of  things  a  well- 
fitting  abdominal  bandage  may  afford  a  very  useful  support.  I 
have  known  cases,  not  only  of  irritable  uterus,  but  of  severe 
nervous  symptoms  (in  one  instance  epileptoid  convulsions),  to  be 
essentially  relieved  by  wearing,  for  months  together,  external 
abdominal  supporters. 


Hodge's  Pessary. 


Fig.  136. 


A.  H.  Smith's  Pessary. 


Ulcers  of  the  Uterus. — Much  discussion  has  occurred  as  to  the 
fitness  of  the  application  of  the  term  ulcer  to  such  "granular 
degenerations,  erosions,  or  abrasions"  as  are  observed  about  the 
OS  and  cervix  of  the  uterus.  The  term  is,  however,  thus  applied 
by  most  gynaecologists.^  Thomas  describes  six  varieties  of  cer- 
vical ulcerations  :  1.  Granular ;  2.  Follicular  ;  3.  Inflammatory  ; 
4.  Syphilitic ;  5.  Corroding ;  6.  Cancerous. 

Of  these,  the  granular  ulceration  of  the  vaginal  (exterior) 
surface  of  the  cervix  is  the  most  frequent.  Its  symptoms  are 
sometimes  slight,  in  other  cases  quite  grave.     It  is  pi'oduced  by 


1  N.  Y.  Med.  Record,  June  19,  1880,  p.  688. 

2  Dr.  Reamy,  of  Cincinnati  (1880)  in  8000  women  examined,  found  (excluding  syph^ 
iUtic  and  cancerous  cases)  but  19  instances  of  what  he  regarded  as  "  true  ulceration." 


UTERINE    TUMORS.  669 

all  causes  of  uterine  irritation  or  inflammation,  as  displacements; 

sexual  (if)uscs;  2>'i'<'ssure ;  iiijurics  during  parturition. 

In  a  serious  case  the  sym])toms  may  be  as  follows :  leucorrhcea^ 
sometimes  bloody  or  puruUiuL;  ^Kf/n  and  bloodt/  discharge  after 
coition;  menorrliagia ;  j)ain  on  locomotion;  constant  pain  in  the  hack 
and  loins;  gener<d  debilitg  and  hysterical  disorder. 

Examination  by  means  of  the  vaginal  touch  and  the  spjendiim 
will  make  certain  the  presence  or  absence  of  ulceration,  "The 
cervix,  more  especially  near  the  os,  is  seen  to  be  covered  by  a 
mass  of  pus,  which  being  removed  lays  l)are  an  intensely  red, 
granular,  hemorrhagic-looking  space  of  greater  or  less  extent, 
closely  resembling  the  inner  surface  of  the  eyelids  when  aflected 
by  granular  degeneration.  The  diseased  surface  does  not  appear 
depressed  below,  but  is  sometimes  even  elevated  above  the  sur- 
rounding mucous  membrane."     (Thomas.) 

Treatment. — The  ulcer  of  the  uterine  cervix  is  to  be  regarded 
as  the  sign  and  eftect  of  a  morbid  condition  of  the  uterus  itself. 
Endometritis  (inflammation  of  the  lining  membrane  of  the  uterus) 
or  congestion  of  the  body  or  neck  of  the  womb,  may  exist  and 
requii'e  treatment.  Or,  a  displacement  may  be  causing  continual 
irritation,  by  friction  of  the  os  or  cervix  against  the  floor  of  the 
pelvis. 

For  the  ulcer  itself,  authorities  advise  the  application  of  caws- 
tics,  especially  the  solid  nitrate  of  silver ;  and  astringents,  as  the 
"styptic  colloid"  of  Richardson.  The  latter  is  essentially  a 
strong  solution  of  tannic  acid  in  collodion.  The  speculum  is 
required  for  the  effectual  localization  of  the  effect  of  caustic, 
which  should  not  be  used  without  care  and  observation  of  its 
effects.  Once  a  week  will  usually  be  sufficient  for  the  applica- 
tion. Confidence  in  this  mode  of  treatment  is  less  general  than 
it  was  twenty  years  ago. 

Vaginal  .sMjjposiioHes  are  sometimes  employed  ;  consisting  of  tan- 
nin^ oxide  of  zinc,  alum,  extract  of  belladonna,  iodoform,  or  opAum, 
made  up  Avith  starch  or  gum,  glycerin  or  cacao-butter,  to  the 
proper  size  and  shape.  Astringent  washes,  also,  are  serviceable ; 
used  once  or  twice  every  day,  consisting  of  alum,  sulphate  of  zinc, 
or  tannin,  with  glycerin  and  tepid  or  wai'm  water.  A  drachm 
of  sulphate  of  zinc,  or  two  drachms  of  alum  or  tannin,  with  an 
ounce  of  glycerin  and  a  gallon  of  water,  will  be  strong  enovigh. 

For  the  description  and  treatment  of  other  varieties  of  ulcer 
of  the  iiterus,  we  must  refer  the  student  to  special  works  on 
Gynaecology. 

UTERINE  TUMORS. 

Morbid  growths  may  occur  on  the  exterior  ox  interior  surfaces 
of  the  uterus,  or 'in  the  substance  of  its  walls,  A  simple  classi- 
fication of  them  is  into  fhroid  tumors  (myo-fibromata),  fibro- 
cystic tumors  (cysto-fibromata),  uterine  polypi,  and  cancers  of  the 
uterus. 

Fibroid  tumors  are  the  most  frequent.     Generally  there  is  but 

one  developed  in  the  same  uterus ;  commonly  in  the  body  or 

fundus.     Occasionally  several  occin-  at  a  time,  and  attain  a  great 

size.     The  tissue  of  the  tumor  is  firm  and  tough,  creaking  when 

48* 


570  UNCX,ASSIFIED    DISEASES. 

cut.  Microscopically,  it  consists  of  "long,  fine  fibres,  generally 
united  in  bundles;  of  fusiform  fibre-cells,  analogous  to  fibro- 
plastic elements ;  and  of  round  or  elliptic  granules  of  small  size  ; 
the  whole  being  bound  together  by  fine  intercellular  substance." 
All  of  these  are  derived,  by  modification,  from  the  normal  tis- 
sues of  the  womb ;  chiefly  the  connective  tissue,  but  in  part  the 
smooth  muscular  tissue  also.  The  negro  race  is  especially  liable 
to  fibroid  tumors  of  the  uterus.  They  occur  most  frequently  be- 
tween the  agesof  thirty  and  forty-five;  especially  in  sterile  women. 

Symptoms. — These  vary,  on  account  of  the  complications  and 
secondary  effects  of  morbid  enlargements  or  growths  of  the  uterus. 

There  may  be  excessive  menstrual  flow  (menorrhagia) ;  inter- 
mediate or  constant  hemorrhage  (metrorrhagia) ;  irritability  of 
the  bladder  and  lower  bowels ;  pain  in  the  pelvic  region ;  uterine 
tenesmus,  or  bearing-down  pains ;  leucorrhoea ;  dysmenorrhcea ; 
and  signs  of  pressure  on  the  crural  vessels  and  nerves. 

Physical  Signs. — These  may  require  the  use  of  vaginal  touch, 
bimanual  palpation  through  the  vagina  and  abdominal  walls, 
recto-vaginal  palpation,  and  the  speculum;  sometimes,  the  dilata- 
tion of  the  OS  and  cervix  uteri  with  tents. 

By  such  means  we  may  discriminate  between  fibroid  tumor  of 
the  uterus  and  anteflexion  or  retroflexion ;  ovarian  tumors ;  fecal 
accumulation  in  the  large  intestine ;  pelvic  hsematocele  (bloody 
tumor  from  hemorrhage  within  the  pelvis) ;  pelvic  cellulitis 
(inflammation  of  the  areolar  or  connective  tissue  around  the 
uterus) ;  and  pelvic  abscess. 

Treatment. — Spontaneous  cure  of  fibroid  tumors  sometimes 
occurs  by  absorption,  expulsion,  sloughing,  or  calcareous  degenera- 
tion. Much  more  frequently,  when  they  have  obtained  a  mod- 
erate size,  they  remain  stationary  until  the  period  of  the  cessa- 
tion of  the  menses ;  after  which  they  undergo  slow  atrophy. 
Palliation  of  their  symptomatic  effects  is,  in  most  cases,  the  only 
proper  treatment.  Sometimes  life  is  threatened  by  irritation 
and  exhaustion.  Then  an  operation  for  the  removal  of  the 
tumor  is  justified,  if  it  appear  practicable.  This  may  also  be 
proper  when  the  enlargement  is  so  situated  as  to  be  easily 
removed  without  much  injury  to  the  parts  involved. 

The  methods  of  treatment  resorted  to  for  the  cure  of  uterine 
fibroid  tumors  are  these:  absorption;  excision;  Scrasement;  enucle- 
ation; sloughing;  incision;  gastrotomy. 

Absorption  has  been  attempted  by  the  internal  or  hypodermic 
administration  of  medicines;  as  chlorate  of  potassium,  iodine, 
iodide  and  bromide  of  potassium,  ergotin  (Hildebrandt)  and  sev- 
eral mineral  waters.  Although  successful  results  have  been 
asserted,  the  dependence  of  the  recovery  upon  the  medicinal 
agent  used  remains  in  doubt.  Ergot,  or  ergotin,  is  certainly 
always  worth  trial. 

Excision,  by  means  of  a  knife  or  scissors,  may  be  practised 
when  a  small  fibroid  projects  into  the  uterine  cavity,  so  as  to  be 
within  reach  after  dilatation  of  the  cervix  by  tents. 

Ecrasement,  i.  e.,  cutting  away  at  the  base  by  the  ecraseur  or 
chain-saw  of  Chassaignac,  is  to  be  preferred  in  certain  cases  to 
excision. 


UTERINE    TUMORS.  571 

Braxton  Hick's  wire-rope  t'craseur  will  sometimes  answer  still 
better  for  the  same  purpose.  A  very  large  tumor,  (illing  the 
vagina,  may  be  drawn  down  by  obstetric  forceps  and  extruded  so 
as  to  be  cut  away  by  the  knife  or  ecraseur ;  or  it  may,  in  situ,  be 
cut  away  piece  by  piece  to  the  base.  It  is  only  when  the  tumor 
is  small  and  near  the  cervix  that  excision  is  suitable ;  and  the 
use  of  the  ccraseur  requires  that  the  attachment  should  be 
smaller  than  the  body  of  the  tumor. 

Enucleation  is  an  operation  including  (after  dilatation  of  the 
cervix  by  tents)  the  making  of  one  or  more  incisions  into  the 
body  of  the  tumor,  and  then,  by  introducing  the  finger  or  a 
blunt  instrument,  detaching  it  forcibly  from  its  base.  This  is 
attended  by  considerable  danger,  especially  of  peritonitis  and 
pyaemia.  Dr.  West  reports  a  mortality  of  14  out  of  28  cases 
operated  upon  in  this  manner. 

Slougkinghas  been  sometimes  artificially  inducedl)y  '^gouging" 
the  tumor;  i.  e.,  cutting  a  deep  circular  hole  in  it,  and  filling  it 
with  oiled  lint.  This  is  certainly  a  dangerous  procedure,  seldom 
justifiable  in  practice. 

Incision  is  performed  in  some  cases,  where  removal  is  not  prac- 
ticable ;  with  the  view  of  impeding  the  nutrition  and  growth  of 
the  tumor.  A  bistoury  or  scissors  may  be  used  ;  and  the  opera- 
tion may  be  repeated  several  times.  Although  blood  flows  freely 
at  the  time,  it  often  happens  that  the  tendency  to  hemorrhage  is 
diminished  by  the  change  produced  in  the  tumor.  This  is  a  much 
less  violent  and  dangerous  practice  than  gouging  or  enucleation. 

Gastrotomy  is  the  opening  of  the  abdomen  by  the  knife  for  the 
removal  of  a  tumor.  It  is  so  serious  an  operation  that  few  sur- 
geons will  undertake  it  for  uterine  fibroids.  Extirpation  of  the 
uterus  itself  has  been  performed,  with  the  result  of  28  deaths  in 
35  cases.  Gastrotomy  for  the  excision  of  fibroid  tumors  from  the 
uterus  has  met  with  about  1  success  in  4  cases.  The  method  of 
procedure  is  the  same  as  in  ovariotomy.  Its  perils  are,  1,  shock  ; 
2,  hemorrhage  ;  3,  peritonitis  ;  4,  septicaemia  or  pyaemia. 

Oophorectomy  (spaying,  removal  of  both  ovaries,  Battey's'  opera- 
tion) has  in  some  instances  been  followed  by  the  absorption  and 
disappearance  of  uterine  fibroids.  Hegar,  Wells,  Peaslee  and 
Goodell  insist  that  this  operation,  x^erformed  after  maturity,  does 
not  impair  the  feminine  attributes  of  appearance,  voice  or  de- 
meanor. A  few  deaths,  however,  have  resulted  from  the  operation.^ 
Dr.  T.  G.  Thomas  considers  it  more  difficult  and  dangerous  than 
ovariotomy. 

Fibro-cystic  tumors  are  formed  by  the  degeneration  of  solid 
tumors,  so  as  to  render  their  contents  partly  or  wholly  fluid.  This 
may  occur  with  malignant  as  well  as  benign  formations.  It  is, 
however,  uncommon.  The  diagnosis  of  such  tumors  requires  their 
discrimination  from  pregnancy,  ovarian  cysts,  and  ordinary  fibroids 
of  the  uterus.  Their  treatment  should  be  conducted  upon  pre- 
cisely the  same  principles  as  that  of  the  latter. 

Polypi  are  tumors  covered  by  the  mucous  membrane  of  the 

1  Koeberle  first  performed  it  In  1869 ;  Hegar,  of  Freiburg,  in  July,  1872 ;  Lawsou  Tait, 
Aug.  1,  1872,  and  R.  Battey,  of  Georgia,  Aug.  17,  1872. 
a  N.  Y.  Med.  Record,  April  10,  1880,  p.  415. 


672  UNCLASSIFIED    DISEASES. 

womb,  and  attached  to  it  by  a  stem  or  pedicle.    Thomas  mentions 
four  kinds  ;  cellular.,  glandulai\  fibrous^  and  fibrinous  polypi. 

The  symptoms  attending  uterine  polypus  are  of  two  kinds ;  irri- 
tative to  the  uterus  and  thus  disturbing  to  the  general  system,  and 
obstructive  to  the  process  of  menstruation.  The  health  of  the 
patient  is  gradually  lowered,  so  that,  without  violent  disturbance, 
life  is  apt  to  be  shortened  through  debility  and  ansemia. 

Treatment. — Palliation,  of  the  symptoms  is  often  possible  : 
through  appropriate  support  of  the  uterus  by  means  of  a  pessary  ; 
keeping  the  patient  in  bed  at  the  time  of  menstruation,  to  prevent 
excessive  loss  of  blood,  to  which  she  is  rendered  liable  by  the 
presence  of  the  polypus ;  strengthening  the  system  by  tonics  and 
good  diet,  and  by  the  avoidance  of  severe  fatigue ;  and  the  intro- 
duction into  the  vagina  at  night  (after  syringing  with  tepid  water), 
of  a  suppository  of  tannin  and  cacao-butter  ;  with  the  addition  to 
it  of  one  or  two  grains  of  opium  when  there  is  considerable  pain. 

Curative  treatment  requires  a  surgical  operation  ;  which  is  not 
to  be  resorted  to  in  every  case ;  having  danger,  even  to  life, 
attending  it.  An  intra-uterine  polypus,  above  the  os  internum.,  is 
the  most  serious  to  interfere  with.  Vaginal  polypi  may  be  very 
safely  removed.  The  methods  of  operation  are — excision,  torsion, 
ligation,  ^crasement,  and  galvano-cautery. 

Excision  is  performed,  according  to  circumstances,  either  with  a 
knife,  scissors,  or  curved  "polyptome;"  torsion,  by  seizing  the 
tumor  with  forceps  and  twisting  it  off  at  the  neck ;  ligation  is 
tedious,  and  is  now  seldom  resorted  to  ;  the  ecraseur  and  the  gal- 
vano-caustic  wire  are  preferred,  for  expedition  and  safety  (in  skil- 
ful hands)  in  some  of  the  more  difficult  cases. 

Cancer  of  the  uterus  presents  a  general  resemblance  to  cancer 
of  other  organs.  It  is  more  frequent  in  the  uterus  than  in  any 
other  part  of  the  body.  Its  characteristic  is  malignancy  ;  i  e., 
tendency  to  indefinite  growth,  destructive  changes,  involvement 
of  neighboring  parts,  constitutional  depravation,  and  disposition 
to  return  after  surgical  removal.  Some  pathologists  distinguish 
epithelioma  or  cancroid  from  carcinoma  or  true  cancer ;  yet  the 
former  is  not  devoid  of  malignancy,  though  exhibiting  it  often  in 
less  positive  degree.  Carcinoma  of  the  uterus  is  divisible  into 
three  kinds  :  scirrhous,  colloid,  and  encephaloid.  The  cervix  is  the 
part  of  the  uterus  most  often  attacked.  The  scirrhous  form  or 
hard  cancer  is  rare :  the  colloid  or  jelly-like  form  less  so  ;  the 
encepjhaloid  or  soft  cancer  is  the  most  frequent.  The  duration  of 
cancer  of  the  womb,  from  its  beginning  until  death,  varies  from  a 
few  months  to  several  years ;  average  rather  less  than  two  years. 
It  seldom  occurs  before  middle  life  ;  the  greatest  number  of  cases 
being  met  with  between  40  and  50  years  of  age. 

Symptoms. — These  are  as  follows  :  pain  in  the  pelvic  region  ; 
tenderness  ;  menorrhagia ;  leucorrhoea,  with  offensive  odor ;  dark, 
bloody,  grumous  discharge ;  progressive  general  debility  ;  and 
sallow,  cachectic  appearance.  Pain  is  not  always  severe  ;  in  a 
few  cases  it  is  absent. 

Physical  Signs. — By  vaginal  touch,  the  morbid  character  or 
destruction  of  the  uterine  tissue  may  be  perceived.  If  a  very 
small  portion  can  be  removed  without  much  disturbance,  it  may 


PROLAPSUS    OF    THE    OVARIES.  573 

be  examined  witli  the  microscope.  The  characters  of  the  discliarge 
are  always  very  im])()rtaat  in  the  diagnosis.  Care  is  needful  to 
distinguish  cancer  from  jKipillary  growlh  upon  the  cervix  uteri ; 
Xjoliipus ;  fibroid  twnor ;  bleeding  idcer  ;  and  .sijjjhilitic  ulcer. 

Treatment. — As  stated  by  Professor  Thomas,  the  indications 
are — to  destroy  or  remove  the  cancer  ;  to  check  hemorrhage  ;  to 
relieve  suffering ;  to  correct  fetor ;  and  to  improve  or  support  the 
general  strength. 

Anqmtation  of  the  neck  of  the  uterus  is  the  only  operation  that 
affords  much  hope ;  and  this  only  when,  at  an  early  stage  of  the 
disease,  it  can  be  made  to  include  all  of  the  caiicerous  formation. 
Caustics  have  been  very  often  used,  but  without  encouraging 
success,  in  any  form  but  that  of  cancroid  or  epithelioma. 

Palliative  measures  are  to  be  resorted  to  upon  general  princi- 
ples, according  to  the  indications  above  mentioned.  Pain  will 
often  require  opiates,  by  the  mouth,  vagina,  or  rectum.  Fetor 
may  be  corrected  by  the  use  of  washes,  containing  dilute  solu- 
tions of  carbolic  acid,  chlorinated  soda,  permanganate  of  potas- 
sium, etc.  All  but  the  last  named  may  be  made  with  glycerin 
as  well  as  with  water.  The  constitutional  strength  should  be 
supported  by  generous  diet,  milk,  beef-tea,  and,  in  appropriate 
cases,  stimulants. 

John  Clay  has  lately  (1879)  asserted  the  cure  of  a  number  of 
cases  of  uterine  cancer  by  the  use  of  Cliian  turpentine.  Other 
practitioners  have,  on  trial,  not  confirmed  his  report. 

Pelvic  Hsematocele  is  a  "  tumor  formed  by  the  extravasation 
of  blood  into  the  pelvic  tissues  in  the  immediate  neighborhood 
of  the  uterus  ;  and  generally  associated  with  some  derangement 
of  the  menstrual  function." 

Pelvic  Cellulitis. — Synonyms:  Peri-metritis^  Pelvic  Peritonitis^ 
Peri-uterine  cellulitis  (Thomas),  etc.  This  is  inflammation  of  the 
connective  or  cellular  tissue  and  peritoneum  surrounding  the 
uterus  in  the  pelvis.  It  is  mostly,  but  not  always,  when  at  all 
severe,  followed  by  abscess. 

These  last  aflections  are  both  uncommon,  and  are  treated  of 
at  length  in  works  on  Gynsecology  ;  to  which  we  may  refer  the 
reader  for  their  treatment.' 

PROLAPSUS   OF  THE  OVARIES. 

As  described  by  Dr.  Goodell,^  when  the  abdominal  walls  are 
relaxed,  and  one  or  both  ovaries  congested  (as  by  excessive  sex- 
ual irritation)  a  descent  of  one  or  both  may  take  place ;  the  dis- 
placed organ  forming  a  small  tumor  in  "Douglas's  pouch,"  be- 
tween the  uterus  and  the  sacrum.  The  ovai-y  may  sometimes 
get  into  the  sac  of  a  femoral  hernia  ;  or  into  one  of  the  labia 
majora.  In  such  cases,  it  may  be  felt ;  and  so  it  may  sometimes 
in  Douglas's  pouch,  when  it  is  swollen  during  the  menstrual 
period. 

Symptoms  of  ovarian  prolapsus  are,  local  pain,  in  walking, 

1  See  also  excellent  articles  upon  both,  by  W.  0.  Priestly,  iu  Keynolds'  System  of 
Medicine,  Amer.  edition,  Vol.  III. 

2  Med.  News  and  Library.  November,  1879. 


574  UNCLASSIFIED    DISEASES. 

during  coition,  when  the  rectum  is  loaded,  and  worst  of  all,  in 
defecation  ;  also,  usually,  lowness  of  spirits.  The  pain  is  of  a 
"sickening  "  character,  like  that  caused  in  a  man  by  a  blow  or 
pressure  upon  the  testicle.  On  examination  per  vaginiim^  the 
ovary  may  be  more  or  less  distinctly  felt ;  and,  when  pressed  with 
the  finger,  this  sickening  pain  is  at  once  produced. 

Treatment. — Besides  general  measures  of  invigoration,  adapted 
to  each  case,  in  those  attended  by  much  pain  during  locomotion, 
rest  is  important  for  a  time.  Also,  the  replacement  of  the  ovary 
(which,  if  one  only  be  dislocated,  is  generally  the  left  one)  may  be 
promoted  by  the  patient  remaining  for  some  minutes  once  or 
more  every  day  in  the  knee  breast  position ;  atmospheric  press- 
ure being,  at  the  same  time,  made  to  aid  the  reduction  by  the 
vulva  being  distended  to  admit  the  entrance  of  air  into  the  va- 
gina. Dr.  Goodell  advises,  in  cases  giving  evidence  of  ovarian 
engorgement,  the  administration  of  bromide  of  potassium  and 
tincture  of  digitalis.  Other  alteratives  maj^  be  called  for  in  par- 
ticular cases. 

SPERMATORRHCEA. 

Eeferring  the  reader  for  a  full  consideration  of  this  subject  to 
Bartholow,'  Acton,  or  other  authorities,  the  main  facts  only  will 
be  here  stated.  In  continent  men  of  full  health,  an  involuntary 
seminal  discharge  during  sleep  once  in  two  or  three  weeks  is 
common  ;  and  is  then  so  innocent  as  to  be  regarded  by  many 
as  physiological  or  normal.  More  frequent  emissions  are  abnor- 
mal, in  proportion  to  their  frequency;  and  may  cause  much  loss 
of  strength.  While  hemorrhoids,  worms  in  the  bowels,  etc., 
may  occasionally  promote  this,  the  cause  of  actually  excessive 
spermatorrhoea,  in  ninety-nine  cases  (at  least)  in  a  hundred,  must 
be  believed  to  be  self-abuse.  The  cure  of  this  habit  is,  not  always 
at  once,  but  almost  certainly  in  the  end,  the  cure  of  the  resulting 
spermatorrhoea.  The  disastrous  effects  so  obvious  in  many  cases 
are  duo  first  to  the  vicious  habit,  and  secondarily  onlj',  to  the 
involuntary  discharges. 

In  pathology,  Lallemand  was,  for  a  long  time,  allowed  to 
impose  upon  the  medical  mind  his  oj^inion  that  irritation  or 
inflammation  of  the  prostatic  portion  of  the  urethra  is  the  general 
or  universal  immediate  cause  of  spermatorrhoea.  As  Bartholow 
more  correctly  states,  this  is  quite  exceptional.  More  largely 
by  far,  spermatorrhoea  shows  itself  to  be  a  spinal  neurosis.  That 
is,  the  error  is  not  in  the  local  structure  of  the  urethra,  but  in 
the  morbid  nervous  excitability,  which  renews  too  often  the 
sexual  orgasm,  somewhat  after  the  manner  of  an  eclampsia  or 
convulsion,  as  a  reflex  act. 

It  is  to  be  remembered  tliat,  in  a  relaxed  state  of  the  system, 
especially  in  those  whose  genital  organs  have  been  more  or  less 
abused  in  natural  or  unnatural  ways,  sometimes  a  mucous  dis- 
charge of  small  amount  may  occur  from  the  urethra,  like  the 
leucorrhoea  of  the  female.  Only  the  presence  of  spermatozoa, 
visible  with  the  microscope,  proves  seminal  loss. 

What  are  we  to  do,  then,  when  consulted  by  a  patient  for  sper- 

1  On  Spermatorrlioea,  etc.    By  Roberts  Bartholow,  A.M.,  M.D.,  etc. 


SPERMATORRHCEA  575 

matorrhnca?  Ascertain  the  frequency  of  the  discharges,  the  state 
of  his  <i!;eneral  health,  and,  if  possible,  his  hal)its.  Relieve 
unwarranted  alarm  by  statinp:  the  innocence  of  hi-vxeklij  spon- 
taneous evacuation  of  the  seminal  ducts  ;  whose  efiect  is  quite 
dillerent  from  that  of  the  unnatural  violence  and  mechanical 
irritation  of  self-indulgence.  Impress  upon  him,  whether  the 
habit  be  acknowledged  or  not,  that  his  danger  lies  in  it,  and  that 
his  cure  depends  upon  entire  and  permanent  abstinence. 

To  promote  this,  all  moral  impressions  must  be  brought  to 
bear  upon  his  mind,  as  well  as  prudential  considerations.  Active 
muscular  exercise  in  the  open  air  (in  proportion  to  strength) 
should  be  encouraged,  even  to  fatigue.  He  should  eat  very  Ught 
suppers,  sleep  under  light  clothes,  rise  early,  and  bathe  often  in 
cool  or  cold  water.  The  shower-bath  will  do  very  well.  Iron  is 
requii'ed  in  really  weak  cases,  as  a  tonic.  The  diet  should  be 
nourishing,  but  not  stimulant ;  avoiding  high  seasoning,  and 
jilcoholi-c  beverages. 

Of  all  drugs  said  tobeanaphrodisiac  (i  e.,  capable  of  diminish- 
ing or  quelling  sexual  appetite)  I  doubt  whether  any  have  avail- 
able power  except  lupulin,  gelsemium,  and  bromide  of  potas- 
sium. The  dose  of  lupulin  for  this  purpose  is  ten  grains,  at 
bedtime.  Bromide  of  potassium  is,  however,  the  medicine  of  the 
day  for  redwing  excitahiliti/  of  organs  subject  to  reflex  action. 
Twenty  grains  at  bedtime,  ever}-  night,  will,  according  to  my 
observation  in  practice,  make  a  great  difference  in  those  who  are 
troubled  with  frequent  nocturnal  discharges.  Hi/drate  of  chloral 
is  reported,  bj^  Dr.  J.  B.  Bradbury,^  to  have  been  curative,  in  two 
cases  ;  fifteen  grains  having  been  given  every  night.  Trousseau 
commended  belladonna  for  the  same  indication.  Stephanides 
asserts  the  advantage  of  jJyiy-grain  dose  of  atropia  at  bedtime. 
Bartholow  speaks  well  of  the  effect  in  such  cases  of  gelsemium. 

Lallemand's  porte-caustique  finds  justification  only  upon  his 
theory  of  urethral  or  prostatic  disease  being  the  caxise  of  sper- 
matorrhoea. Without  feeling  warranted  in  denying  the  occasional 
existence  of  such  a  lesion,  and  the  possible  benefit  of  limited  cau- 
terization in  such  an  exceptional  case,  I  am  not  able  to  believe 
in  its  frequency  or  great  importance. 

Acton, 2  however,  has  coniidence  in  cauterization  in  a  number 
of  cases.  He  employs  a  solution  of  nitrate  of  silver,  ten  grains 
to  the  ounce  of  water  ;  wdiich  he  injects  into  the  urethra  by  means 
of  an  instrument  consisting  of  a  glass  syringe  attached  to  a  tube 
like  a  short  catheter.  The  part  to  be  acted  upon  is  the  irritable 
membranous  portion  of  the  urethra.  Before  using  the  caustic  the 
patient  should  empty  the  bladder.  The  pain  of  the  application 
is  considerable.  After  the  operation,  Actoia  advises  a  copaiba 
capsule  every  eight  hours,  for  two  or  three  days ;  also,  that  the 
patient  drink  as  little  water  as  possible,  and  avoid  passing  urine 
as  long  as  he  can.  After  once  urinating,  he  is  allowed  to  drink 
watery  fluids  as  usual.  The  scalding  and  oozing  of  blood  gradu- 
ally disappear. 

1  Brit.  Med.  Journal,  April  8,  1871. 

2  On  the  Eeproductive  Organs,  Phila.  ed.,  p.  243. 


576  UNCLASSIFIED    DISEASES. 

Mechanical  means  are  sometimes  employed  to  prevent  nocturnal 
emissions  ;  e.  (/. ,  a  light  metallic  ring  to  surround  the  penis,  having 
teeth  projecting  inwards ;  so  that  erection  awakes  the  patient. 
In  bad  cases,  where  epilepsy,  insanity,  or  extreme  general  exhaus- 
tion has  followed  a  seemingly  incurable  habit  of  self-abuse, 
circumcision  would  seem  to  be  justifiable ;  more  so,  surely, 
than  the  more  serious  and  dangerous  operation  of  castration. 
Baker  Brown's  analogous  operation  to  remove  "peripheral  irrita- 
tion" as  a  cause  of  grave  nervous  maladies  in  the  other  sex,  by 
excision  of  the  clitoris,  has  met  with  very  decided  opposition 
from  Dr.  Charles  West,  of  London,  as  well  as  from  others. 

As  signs  of  waste  of  substance  and  vigor  by  seminal  losses,  we 
find  mentioned,  pallor,  with  dark  lines  under  the  eyes  ;  inabihty 
to  look  any  one  in  the  face  ;  cold,  moist  hands  ;  frequent  flushing 
of  the  countenance ;  aversion  to  society.  But  these  symptoms 
of  general  and  nervous  debility  may  all  exist  without  being  thus 
accounted  for. 

WOEMS— ENTOZOA. 

Helrainthology,  the  study  of  worms,  has  assumed  of  late  a  very 
considerable  imjiortance  in  connection  with  medicine.  About 
thirty  entozoa  inhabit  diftercnt  parts  of  the  body  of  man.  They 
have  been  generally  classified  as  Coelelmintha  or  hollow  worms, 
and  Sterelmintha  or  solid  worms,  i.  e.,  without  any  well  defined 
alimentary  cavity.  Broad  or  flat  worms,  Platehnia.  and  thread- 
like or  cord-shaped  worms,  Nematelmia,  constitute  another 
arrangement.  Of  the  flat  worms,  some  are  Cestoid,  or  ribbon- 
like ;  others  Tremutoid,  or  fluke-like.  The  most  important  ones 
are  enumerated  in  the  following  table : — 

Cestoid  Worms : 
Mature:  Tjjenia  solium;  Taenia  echinococcus; 

Tsenia  mediocanellata;  Bothriocephalus  latus. 
Immature:  Cysticercus  cellulosse;   Cysticercus  t.  mediocanellatse; 
Echinococcus  hominis. 

Trematoid  Worms : 

Distoma  hepaticum  (fasciola  hepatica);     Bilharzia  hematobia; 
Distoma  ophthalmobium;  Tetrastoma  renale. 

Nematoid  Worms : 

Ascarls  lumbricoides;  Sclerostoma  duodenale; . 

Trichocephalus  dispar;  Filaria  medinensis; 

Oxyuris  (ascaris)  vermicularis;   Strongylus  gigas; 
Trichina  spiralis. 

Most  curious  are  the  transformations  which  some  of  these 
parasites  undergo.  Pallas,  1776,  stated  that  all  cystic  worms 
were  forms  of  a  tapeworm.  Steenstrup,  in  1842,  discovered  the 
"alternation  of  generations  "  in  some  small  aquatic  worms,  cer- 
carice.  Kiichenmeister  and  Siebold  proved  by  actual  experiment 
that  hydatid  parasites  are  young  or  immature  tapeworms. 
Humbert,  of  Geneva,  in  1854,  swallowed  fourteen  cysticerci,  and 
in  three  months  discharged  fragments  of  tcenice^  which  had  devel- 
oped within  his  body.     The  immature  forms  are  non-sexual ; 


WORMS  —  ENTOZOA. 


577 


they  may  remain,  as  in  hydatids,  for  a  long  time,  within  solid 
organs,  without  development.  They  only  become  mature  and 
sexual,  capable  of  reproduction,  in  parts  of  the  body  having 
some  communication  with  the  external  air,  as  in  the  alimentary 


Fig.  137. 


Echinocoocus  Hominis. 


canal  or  lungs  ;  generally  the  former.  Migration  from  one  part 
of  the  body  to  another  occurs  with  some ;  e.  g..  trichina  spiralis. 

Taenia  solium  and  Taenia  mediocanellata  look  a  good  deal 
alike ;  but  the  former  is  much  the  smaller.  The  immature  cysti- 
cercus  of  the  former  is  xo^hs  of  an  inch  long  ;  that  of  the  latter, 
of  the  size  of  a  pea.  The  t.  sohum  has  a  circle  of  booklets 
around  a  convexity  of  the  head  ;  the  mediocanellata  is  club- 
headed,  with  larger  sucking  disks  than  the  solium  has.  One  is 
designated  as  "armed"  and  the  other  "unarmed"  tapeworm. 
The  former  is  from  the  custicercus  cellulosce  of  the  hog  ;  the  latter 
from  the  '■'■cysticercus  6om"'  (Cobbold),  and  is  the  most  common. 
The  unarmed  is  the  easiest  to  drive  out. 

The  tapeworm  is  formed  of  flat  segments,  often  several  hundred 
in  number,  connected  with  the  head  by  a  slender  neck.  Each 
segment  has  male  and  female  organs  (hermaphrodite) ;  as  those 
at  the  tail  mature,  they  are  cast  off.  Some  patients  thus  pass 
six  or  eight  fi-agmeuts  from  the  bowels  in  a  day.  The  whole 
length  of  the  pai'asite  is  from  ten  to  thirty  feet. 

The  symptoms  caused  by  tapeworm  are  not  very  determinate. 
They  resemble  those  produced  by  other  worms  ;  namel}',  uneasy 
sensations  in  the  abdomen,  and  general  nervous  irritation  ;  bad 
sleep,  attacks  of  faintness^  lowness  of  spirits,  indigestion,  irregu- 
larity of  appetite  and  of  the  action  of  the  bowels  ;  itching  of  the 

1  Cobbold  states  that  the  hydatid  of  the  cysticercus  bovis  has  never  been  observed  in 
man.  Hydatid  or  "ecblnococcus"  disease  is  especially  frequent  in  Iceland;  one  in 
fifty  of  the  inhabitants  being  affected  by  it. 

49  2M 


578 


UNCLASSIFIED    DISEASES. 


nose,  and  sometimes  of  the  anus.  Epilepsy  and  insanity  are  said 
to  have  been  sometimes  caused  by  it.  The  only  ])roof  of  tape- 
worm is  the  finding  of  fragments  of  it  in  the  stools.  It  is  a  com- 
mon impression  that  it  is  never  destroyed  unless  the  head  is  dis- 
coverable ;  but  this  is  only  generally,  not  alwaj^s,  true.  Con- 
versely, if  the  head  comes  away,  the  parasite  to  which  it  belongs 
is  no  longer  reproduced.  More  than  one  of  them  may,  however, 
be  present  at  once  ;  though  this  is  rare. 

Fig. 138, 


Tsenia  Solium. 

The  broad  tapeworm, 'both.riocephaliis,  is  only  known  in  Central 
Europe,  Russia,  Sweden,  Norway,  Lapland,  Finland,  Poland, 
and  Switzerland.^  Its  head  is  elongated,  compressed,  obtuse  ;  its 
length  from  six  to  twenty  or  twenty -five  feet.  It  does  not  give  off 
detached  segments.  Cobbold  says  it  is  indigenous  to  Ireland ; 
although  he  has  never  met  with  a  patient  born  in  that  country 
who  has  been  the  subject  of  it. 

Treatment  of  Tapeworm. — Oil  of  turpentine,  in  half  ounce  or 
ounce  doses,  will  generally  purge  and  bring  away  the  worm.     It 

1  Frazer  (Dublin  Quarterly  Journal,  Nov.,  1868;  asserts  that  it  has  been  recognized  in 
some  of  the  Italian  cities,  and  that  it  probably  extends  to  Northern  Africa. 


T  R  F  M  A  T  O  D  E    W  O  R  M  S  .  579 

intoxicates  some  persons.     lu  Ei^ypt,  petroleum  is  used  for  the  same 

f)urpose,  in  doses  of  twenty  to  lliirty  drops.  The.  ethereal  extract 
commonly  called  oil)  af  male  fern.,  extractum  Jilicis  liquidmn,  U.  S. 
Pharm.,  in  the  dose  of"  a  drachm  and  a  half  to  two  drachms,  is 
esteemed  highly  hy  Cobbold  and  some  other  practitioners.  Aspi- 
diiim  marginale,  a  fern  indigenous  in  America,  is  almost  or  quite 
as  good  a  vermicide.  Jibos.so,  the  tlower  of  the  Brayera  anthelmin- 
tica  of  Abyssinia,  in  half-ounce  doses,  mixed  with  water,  given  on 
an  empt}'  stomach,  is  almost  certain  to  destroy  or  remove  the  para- 
site. So  is  said  to  be  Kameela.,  the  Botilera  tindoria  of  botanists. 
Pumpkin-seeds,  plentifully  taken  on  an  empty  stomach,  are  quite 
effectual ;  and  so  is  pomegranate-root  bark  ;  or,  better,  its  active 
principle,  pelletitrine.  Dr.  J.  H.  BilP  has  reported  the  cure  of  a 
case  by  carbolic  acid,  given  in  five-grain  pills  with  extract  of 
liquorice.  Thirty-five  such  xjills  were  taken  without  apparent 
inconvenience.  Others  have  cured  cases  vyith  12-grain  doses  of 
salicylic  acid. 

Prevention  of  Tapeworm. — As  immature  tapeworms  find  resi- 
dence in  the  bodies  of  animals  used  for  food,  and  thus  get  oppor- 
tunity to  enter  the  human  alimentary  canal,  the  avoidance  of  raw 
or  under-cooked  meat  is  the  precept  of  prophylaxis  suggested,  and 
confirmed  by  experience.  This  applies  not  only  to  the  preven- 
tion of  tapeworm,  but  also  to  that  of  other  parasites,  especially 
trichina.  Tapeworms  are  derivable  from  infested  beef,  even 
oftener  (Cobbold)  than  from  pork.  Mutton  has  been  found 
occasionally  to  contain  cysticerci. 

TKEMATODE   WORMS. 

These  are  the  Distomata,  Bilharzia  hcematohia,  tetrastoma  renale., 
and  others.  They  are  of  a  flattened  oval  shape,  soft  and  smooth. 
They  have  a  bifurcating  alimentary  canal,  with  a  mouth,  but  no 
anus.  Both  sexes  are  upon  one  individual.  They  exist  in  two 
conditions  ;  mature  and  encysted,  and  immature  and  free.  Their 
methods  of  reproduction  are  very  curious,  but  of  greater  impor- 
tance in  zoological  than  in  pathological  science. 

Distoma  hepaticum,  found  sometimes  in  the  liver  and  its  ducts, 
measures  about  an  inch  in  length  when  mature,  and  rather  less 
than  half  an  inch  in  width. 

Distoma  ophthalmobium  has  been  discovered  in  the  eye  of  a 
child  having  congenital  cataract.  It  is  about  half  a  line  (^  in.) 
in  length. 

Biliiarzia  haematobia  exists  in  abundance  in  Egypt ;  where  it 
Inhabits  the  veins  of  the  abdominal  organs  of  the  inhabitants,  in 
the  proportion  of  nearly  one-third  of  the  population.  Hemor- 
rhage from  thekidney,'andthe  symptoms  of  dysentery,  may  follow 
from  its  presence.  It  is  not  more  than  three  or  four  lines  (^  to  ^ 
in. )  in  length.     The  sexes  are  on  different  individuals. 

Tetrastoma  renale  is  occasionally  found  in  the  substance  of 
the  kidney.     It  is  nearly  half  an  inch  long. 

1  N.  Y.  Medical  Record,  Nov.  15, 1873. 


680  UNCLASSIFIED    DISEASES. 


IfEMATOID,   OR  ROTTND  WORMS. 

Ascaris  lumbricoides  is  the  commonest  of  entozoa,  particularly 
in  the  Southern  United  States  and  the  West  Indies.  It  inhabits 
mostly  the  small  intestines ;  but  may  get  into  the  stomach,  and, 
of  course,  the  large  intestines.  I  have  repeatedly  known  it  to  be 
vomited  from  the  stomach.  It  has  sometimes  even  reached  the 
middle  ear.^  This  round  worm  is  from  five  to  fifteen  inches  in 
length,  light-brown  in  color,  tapering  to  a  point  at  each  end. 
A  considerable  number  of  them  may  exist  together ;  it  is  only 
then  that  their  presence  in  the  bowels  is  likely  to  do  much  harm, 
unless  in  very  susceptible  children.  Their  escape  into  the  stomach 
may  cause  nausea,  vomiting,  and  indigestion,  sometimes  difficult 
to  account  for  until  the  throwing  up  of  the  worm  explains  the 
cause.  I  have  known  this  to  happen  in  an  adult,  in  whom  the 
symptoms  of  gastric  irritation  continued  for  two  or  three  weeks. 
These  worms  probably  enter  the  body  chiefly  in  drinking-water 
from  shallow  wells,  muddy  streams,  etc. 

Treatment :  Diagnosis. — Two  things  are  wanted  :  to  expel  the 
worms  present,  and  to  prevent  their  reaccumulation.  Evidence 
of  the  existence  of  lumbricoid  worms  in  the  bowels  is  always 
doubtful  unless  some  of  them  pass  out  with  the  evacuations. 
Their  ova  may  also  be  seen  (Davaine,  Leuckart)  in  the  passages 
with  the  microscope.  Signs  of  gastro-intestinal  and  nervous 
irritation  attend  them,  especially  in  infants  and  young  children. 
So,  grinding  the  teeth  during  sleep,  itching  of  the  nose  and  anus, 
bad  or  irregular  appetite,  and  tumidity  of  the  abdomen,  are 
regarded  commonly  as  signs  of  worms.  But  other  sources  of 
indigestion  and  disturbance  maybe  thus  made  known.  Convul- 
sions may  undoubtedly  be  caused  by  worms  in  children  ;  and  so 
may  laryngismus  stridulus,  and  spasmodic  croup.  Total  suffoca- 
tion has  in  a  few  cases  resulted  from  ascarides  getting  into  the 
air  passages.^ 

When  there  is  good  reason  to  believe  that  they  exist  in  the 
bowels,  anthelmintics  may  be  given,  with  purgatives,  in  safe  doses, 
watching  their  effects.  Besides  the  vermicides  mentioned  in  con- 
nection with  tapeworm,  many  other  drugs  have  more  or  less  such 
effect;  as  santonin  (most  certain  of  all),  calomel,  pink-root  (spi- 
gelia),  bark  of  pomegranate-root,  azedarach,  chenopodium,  cow- 
hage  (mucuna),  powder  of  tin,  etc.     [F.  206,  207,  208.] 

Infusion  of  senna  and  spigelia,  half  an  ounce  of  each  to  a  pint ; 
for  an  adult,  a  wineglassful  every  morning  before  breakfast ;  this 
is  very  popular  in  this  country.  Instead,  may  be  given  fluid 
extract  of  spigelia  and  senna^  a  teaspoonful  or  two  for  a  dose. 
As  above  said,  santonin  is  the  most  effectual  of  the  vermicides 
or  vermifuges.  It  requires  care  in  its  use,  however ;  producing 
serious  vomiting,  prostration,  and  nervous  symptoms  in  over- 
doses. A  child  should  not  take  more  than  half  a  grain  of  san- 
tonin once  or  twice  daily ;  an  adult,  from  three  to  six  grains. 

Dochmius  Duodenalis  is  a  very  small,  almost  cylindrical,  para- 

iDr.  L.  W.  Reynolds  (Lancet,  vol.  ii.,  1880,  p.  653),  reports  a  case  in  which  the  inem- 
brana  tympani  was  perforated. 
2Furst,  Wiener  Med,  Wochenschrift,  1879;  Brit.  Med.  Journal,  Sept.  27,  1879. 


NEMATOID,  OH  ROUND  WORMS, 


581 


site,  met  with  only  in  warm  countries,  as  Italy,  Brazil,  and  Egypt. 
Tlic  male  is  y'V,-  and  the  female  -7,^  of  an  inch  in  length.  It  has  a 
terminal  mouth,  furnished  with  eight  teeth.  Being  taken  into 
tlie  stomacli  in  impure  water,  it  attaclies  itself  to  the  mucous 
membrane  of  the  alimentary  canal,  and  lives  there  on  blood,  like 
a  leech.  Sometimes,  when  present  in  large  numbers,  these  worms 
cause  serious  hemorrhages  from  the  bowels. 

Trichocephalus  dispar.— This  worm  inhabits  the  large  intes- 
tine. It  has  a  length  of  an  inch  and  a  half  to  two  inches.  The 
head  is  attenuated  or  hair-like,  whence  its  name.  The  sexes  are 
on   dilleront  individuals.     The 

trichocephalus  is  much  less  com-  Fig.  139. 

mon  than  the  lumbricoid  worm. 

Oxyuris  vermicularis  ( Ascuris 
vermicidaris).  White  seai-ioorm. — 
Of  this  the  male  is  al:)Out  a  line 
(jV  inch)  and  a  half  long;  the 
female,  five  or  six  lines.  It  is 
found  in  the  rectum,'  generally 
of  children ;  sometimes  in  con- 
siderable numbers.  They  cause 
a  great  deal  of  itching;  occasion- 
ally, other  nervous  irritation. 
Females  may  have  them  find 
their  way  into  the  vagina;  more 
rarely,  they  get  into  the  urethra. 

For  the  treatment  of  seat- 
worms, I  have  known  nothing 
superior  to  siqil^ositories  of  san- 
tonin; made  with  cacao  butter, 
three  grains  of  the  drug  in  each; 
one  to  be  introduced  into  the  rec- 
tum every  night  [F.  209] .  Other 
common  remedies  are,  injections 
of  lime-water,  infusion  of  aloes, 
mercurial  ointment,  etc.  Dr. 
Bond,''  of  Washington,  and  Dr. 

Magruder,  of  Olney,  Maryland,  have  found  great  benefit  from 
the  use  of  the  root  of  asarum  canadense  (wild  ginger  or  Canada 
snake-root).  The  root  may  be  chewed  freely,  or  an  infusion 
may  be  made  (gj  in  Oj),  and  taken  in  wineglassful  doses.  The 
European  species  of  asarum  is  more  irritant  and  less  suitable  for 
this  purpose. 

Trichina  spiralis. — Since  1822,  when  Tiedeman  discovered  it 
(Hilton,  1832),  and  especially  since  it  was  described  by  Paget 
and  Owen  in  1835,  the  dissecting-room  has  furnished  observers 
with  specimens  of  this  parasite,  long  supposed  to  be  harmless. 
Zenker,  of  Dresden,  first  showed  that,  although  a  few  trichince 
maj''  be  innocent,  they  sometimes  abound  to  such  an  extent  as 
to  cause  serious  disease,  and  even  to  destroy  life.     Such  an  affec- 


Trichocephalus  Dispar,  magnified. 
(Leuckart.) 


1  Col  ibold  says,  more  often  the  cwcum. 

2  Phila.  Med.  Times,  Sept.  26,  1874. 


49 


582  UNCLASSiriED    DISEASES. 

tion  is  called  tricliinous  disease,  irichiniasis,  or  trichinosis.  It  has 
occurred  particularly  often  in  Germany,  where  it  has  been  recog- 
nized since  1860,  In  1863,  in  a  Prussian  town,  of  108  persons  in 
good  health  who  dined  together  on  a  festive  occasion,  nearly 
all  became  ill  from  eating  sausage  made  of  the  meat  of  an  ill- 
conditioned  pig ;  and  quite  a  number  died.  Another  outbreak,  at 
Hederslebeu,  in  1865,  caused  40  deaths  in  300  cases.     The  first 

cases  in  America  were  reported  by 
Fig.  140.  Dr.   Schnetter,   of  I^ew   York.^     At 

Marion,   Iowa,   in    1866,   nine   cases 
occurred  in  one  family,  under  the  care 
of  Dr.  J.  H.  Wilson;  five  died.    In  the 
same  county,  eating  raw  ham  contain- 
ing trieliinse  (as  proved  afterwards  by 
po  o,u     examination)  caused  the  disease  in  six 
°  °  °        children  at  one  time;  reported  by  Dr. 
Ristine.     An  examination  of  pork  in 
Chicago,  by  a  committee  of  the  Acad- 
emy of  Sciences  of  that  city,  proved 
Trichiua  in  Muscle,  natural     the  existence  of  trichinoe  in  1  in  .50 
size.  of  the  hogs  inspected;  some  of  their 

muscles  containing  from  10,000  to 
18,000  in  a  cubic  inch.  In  1878,  H.  E.  Atwood  and  Dr.  W.  T. 
Belfield,  of  Chicago,^  found  8  hogs  in  100  to  contain  trichinje. 
About  the  same  time.  Prof.  Heschl,  of  Vienna,  stated  that,  of 
American  hams  imported  into  Korth  Germany,  from  10  to  20 
per  cent,  were  trichinous;  Avhile  the  proportion  in  Westphalia 
haras  was  but  1  in  2000  or  2500.  Atwood  and  Belfield,  in  Chicago, 
did  not  find  the  worms  in  the  hams,  but  in  muscles  of  other  parts 
of  the  hogs  examined.  Such  animals  are  not  themselves  nearly 
always  out  of  health.  Cattle,  also,  are,  to  a  less  degree,  subject 
to  the  same  parasite.  The  meat  of  those  so  infested  should,  of 
course,  not  be  used  for  food.  In  some  German  cities  the  butchers 
have  microscopic  examination  made  of  the  flesh  of  their  animals. 
Dr.  Belfield,^  after  feeding  a  rat  with  trichinous  pork,  ate  a 
portion  of  the  rat's  flesh,  which  had  been  ascertained  by  the 
microscope  to  contain  twelve  trichinae.  At  the  end  of  more  than 
a  month's  time  he  had  suffered  no  inconvenience.  This  confirms 
the  common  belief  that  a  few  trichinae  may,  even  in  man,  be 
harmless.  It  is  when  they  multiply  to  tens  and  hundreds  of 
thousands  that  they  endanger  life. 

To  the  naked  eye,  the  muscles  of  a  trichinous  animal  present 
whitish  dots,  which  a  lens  will  show  to  be  the  capsules  or  C3'sts 
of  immature  trichinae.  Those  not  enc5'sted  are  invisible  without 
a  microscope.  The  capsule  is  hard  and  transparent;  the  worm  is 
coiled  spirally  within  it.  Under  the  tongue  is  the  preferred  place 
to  search  for  the  trichinae  in  the  living  animal;  a  delicate  harpoon 
being  used. 
The  trichina  is  a  minute  bisexual  worm,  reproducing  in  the 

1  Clymer,  in  Phila.  ed.  Aitken's  Practice  of  Medicine,  vol,  i.,  p.  858. 

2  Report  of  Department  of  Health,  Chicago,  1878. 
5  Sanitarian,  July,  1879,  p.  324. 


NEMATOID,  OR  ROUND  WORMS, 


583 


intestinal  canal  of  animals  or  men;  the  offspring  then  finding 
their  way  out  through  the  walls  of  the  intestines  to  become 
finally  encysted  in  the  muscles.  The  disease  produced  by  them 
has  two  distinct  stages:  1.  That  of  the  presence  of  the  worms  in 
the  alimentary  canal,  and  their  multiplication  tliere;  2.  That  of 
their  migration  to  and  location  in  the  muscles.  Of  the  first  period, 
vialaise,  vomiting,  and  diarrhoea  are  the  leading  symptoms.  Of 
the  second,  fever,  resembling  typhoid,  severe  pains,  with  stiffness 
in  the  muscles,  and  prostration.  As  the  muscles  of  the  larynx 
are  often  attacked,  hoarseness  is  a  common  symptom.  The  com- 
plication of  pneumonia  is  not  infrequent.  The  first  stage  above 
mentioned  lasts  about  a  week  or  less;  the  second  may  terminate 
fatally  within  six  days,  but  usually  has  a  duration  of  from  two 
to  four  or  five  weeks.  A  man  died,  however,  in  the  Middlesex 
Hospital  from  phthisis,  in  1874,  in  whose  muscles  millions  of 
tricliince  were  present,  believed  by  the  physicians  in  attendance 
(perhaps  upon  doubtful  evidence)  to  have  been  perpetuated  in  his 
system  for  several  years.' 

We  are  not  informed  of  much  success  with  the  treatment  of 
trichiniasis.  Traube,^  of  Berlin,  is  reported  to  have  obtained 
recoveries,  in  hospital,  under  friction  of  the  limbs  with  bay  salt. 
Others  give  carbolic  acid  internally.  Injection  of  ergotin  into 
the  neighborhood  of  the  affected  muscles  is  said  to  have  done 
good.  As  salicylic  acid  has  been  found  (Hoeberlein)  to  dis- 
solve trichinae  in  flesh  after  death,  it  would  be  reasonable  to 
try  its  administration  during  life.  Glycerin,  in  lar^  doses,  is 
reported  to  have  cured  several  cases  of  trichinosis.^    Prevention 


Fig.  141. 


Fig.  142. 


Trichina  Encysted  in 
Pork. 


Trichina,  magnified  150 
diameters. 


is  always  possible.     Besides  proper  inspection  of  animals,  every 
piece  of  meat  which  may  be  suspected  must  be  well  cooked.    Per- 

»  Lancet,  Jan.  17,  1874.  2  Lancet,  July  8,  1871. 

3  I.  M.  Barton,  College  and  Clinical  Record,  1881. 


584  UNCLASSIFIED    DISEASES. 

roncito,  of  Turin,  proved  that  a  temperature  of  122°  F.  will  kill 
uncovered  trichinae,  as  well  as  other  parasites  of  the  human  body. 
Fiedler  found  that  it  required  a  heat  of  150°  to  160°  F.  to  destroy- 
er? ca/JsztZecZ  trichinae.  This  temperature  is  always  exceeded  in 
cooking,  if  the  whole  of  the  meat  is  exposed  to  the  fire  for  a  suffi- 
cient length  of  time.  Reliance  cannot  be  had  upon  salting  and 
smoking;  at  least  unless  they  be  very  thoroughly  done. 

Sclerostoma  duodenale  is  common  in  Egypt  and  in  parts  of 
Europe.  It  exists  in  the  small  intestines,  and  causes  a  chlorosis- 
like anaemia.  The  worm  is  from  a  third  to  a  half  an  inch  long. 
Its  vermicide  is  said  to  be  turpentine. 

Strongylus  gigas  {Eustrongylus  gigas)  inhabits  the  kidney. 
It  is  rare  in  man. 

Filaria  medinensis  {Dracunculus),  or  Guinea-worm,  lives  in 
the  subcutaneous  tissue.  It  is  common  in  the  tropical  regions 
of  the  old  world.  The  female  worm  enters  the  skin  of  a  human 
being,  and  develops,  with  its  contained  young,  in  a  whip-cord- 
like shape,  to  a  length  varying  from  six  inches  to  four,  five,  or 
six  feet,  and  a  width  of  about  one-twelfth  of  an  inch.  A  dozen 
or  more  of  the  worms  may  exist  upon  the  same  person.  The 
lower  limbs  are  especially  invaded  by  them ;  but  they  can  migrate 
almost  all  over  the  body.  They  evidently  get  into  the  legs  and 
feet  of  those  who  bathe  in  shallow  streams  or  ponds,  or  walk 
barefooted  in  damp  or  muddy  places.  An  incubation  of  a  year 
or  more  is  required  for  the  development  of  the  worm  to  a  per- 
ceptible size. 

A  characteristic  vesicle  appears,  generally  upon  the  lower  part 
of  the  leg,  when  the  worm  matures.  This  bursts,  emitting  the 
young  filarise  ;  a  good  deal  of  itching  and  irritation  ensues,  and 
sometimes  ulceration.  The  natives  often  rid  themselves  of  the 
worm  by  letting  a  stream  of  water  run  or  pour  for  a  time  upon 
the  leg.  When  it  creeps  partly  out,  they  draw  upon  it  until  it 
is  dislodged.  Dr.  Horton^  asserts,  on  the  basis  of  experience  in 
West  Africa,  that  tincture  of  assafoetida  (thirty  drops  three  times 
a  day)  wiil  act  as  a  poison  to  this  parasite. 

Filaria  sang-uinis  hominis,  discovered  in  1872  by  Dr.  T.  R 
Lewis  of  the  British  Army  Medical  Service,  is  a  minute  nema- 
toid  worm,  whose  presence,  even  to  the  number  of  hundreds  or 
thousands,  in  an  individual  body,  does  not  appear  to  produce 
serious  injury  to  health.  Chylous  urine  is  the  most  marked  symp- 
tomatic result.  This  worm  has  an  average  wddth  of  -g-^g^  of  an 
inch ;  length,  ^  inch.  Dr.  Lewis  estimated  that  in  one  of  his 
patients  in  Calcutta  there  must  have  been  140,000  of  these  worms. 
By  aid  of  the  microscope  it  has  been  found  (Cobbold)  th?it  Jilarice, 
of  this  or  allied  species,  can  be  conveyed  to  the  human  body  by 
the  bite  of  the  mosquito,  the  presence  of  these  parasites  in  the 
bodies  of  mosquitos  having  been  demonstrated.  Those  present 
in  human  blood  have  a  length  of  from  ^^  to  ^^,  and  a  thick- 
ness of  about  ^-Jjjo  of  an  inch.  Lewis,  Carter,  and  Cobbold 
assert  that  the  mature  worm  (found  in  blood-clots  and  axillar 
abscesses)  is  about  three  and  a  half  inches  in  length. 

1  Brit,  and  Foreign  Medico-Chirurg.  Keview,  January,  1869,  p.  160. 


POISONS.  685 

Filaria  restiformis  is  the  name  given  by  Dr.  J  Leidy'  to  a 
newly  observed  smooth,  cylindrical  thread-worm,  26  inches  long. 
It  was  passed  from  the  urethra  of  a  patient  of  Dr.  Garnett  of 
West  Virginia.  It  appears  to  be  nearly  related  to  the  Guinea 
worm. 

EPIZOA. 

Parasitic  animals  living  upon  the  surface  of  the  body  are  (besides 
the  sarcopies)  chiefly  lice,  fleas,  and  ticks.  The  former  are  the 
head  louse  (pediculus  capitis),  body  louse  (p.  corporis),  and  crab 
louse  (p.  pubis).  These  are  true  insects,  without  wings.  The 
lyreventive  of  them  is  cleanliness,  with  avoidance  of  contact  with 
unclean  persons.  Their  destruction  must  be  accomplished  either 
by  assiduous  search  and  slaughter,  or  by  parasiticide  lotions, 
ointments,  or  powders ;  as  corrosive  sublimate,  cinnabar,  pyre- 
thrum,  cocculus  iudicus,  sulphur,  carbolic  acid,  staphisagria, 
sabadilla,  alcohol,  essential  oils  [F.  210,  211,  212,  362]. 

Two  or  three  grains  of  corrosive  sublimate  dissolved  in  an 
ounce  of  water,  with  a  drachm  or  so  of  alcohol,  will  be  as 
effectual  as  any  of  these.  Citrine  ointment,  or  white  precipitate 
ointment,  will  do  very  well,  even  if  diluted  one-half  with  lard  or 
vaseline.  Powder  or  ointment  of  cocculus  indicus  is  a  good  deal 
employed.  The  flea-powder  of  the  East  (quite  useful  in  stupefy- 
ing fleas  in  a  bed,  if  sprinkled  before  lying  down)  is  probably 
lyijrethrmn. 

Ticks  belong  with  the  arachnicla  of  naturalists.  People  living 
in  the  country  often  have  them  to  enter  the  skin  from  other  ani- 
mals or  from  plants,  e.g.,  the  harvest-tick  (leptus  autumnalis). 
The  irritation  is  moderate  and  local  only. 

Fleas  in  most  parts  of  the  world  produce  only  annoying  bites, 
larger  and  somewhat  more  inflamed  than  mosquito-bites.  In 
Brazil  and  other  parts  of  South  America  the  chigoe  or  jigger 
{2ndex  penetrans)  makes  a  more  permanent  lodgment,  and  causes 
a  very  considerable  irritation. 

Acarus  folliculorum  (demodex  or  steatozoon  (E.  "Wilson)  fol- 
liculorum)  is  a  tiny  parasite  which  inhabits  the  follicles  of  the 
skin,  especially  upon  the  face  in  acne.  Sometimes  ten  or  twenty 
of  these  acari  may  be  found  in  a  single  sebaceous  follicle.  The 
cephalo-thorax  constitutes  about  one-fourth  of  the  whole  body, 
which  has  a  length  of  Jjj  of  an  inch.  It  is  provided  with  four 
pairs  of  short  legs.  There  is  no  evidence  that  this  parasite  is 
the  cause  of  acne.  More  probably  its  presence  in  the  diseased 
follicles  is  (pathologically  speaking)  accidental.  (See  Acne,  under 
Diseases  of  the  Skin.) 

POISONS. 

A  few  memoranda  upon  the  more  common  poisons  may  be  con- 
venient here.  Toxic  agents  are :  1.  Irritant ;  2.  Narcotic ;  3. 
Unclassified. 

Irritant  or  Corrosive  Poisons.— 1.  Acids;  e.g.,  sidphuric,  nitric, 
chlorohydric,  oxalic.  For  all  but  the  last  any  alkaline  substance 
(carbonate  or  bicarbonate  of  sodium,  potassium,  magnesium,  or 

1  Proc.  of  Acad.  Nat.  Sciences  of  Philadelphia,  March  2, 1880. 


686  UNCLASSIFIED    DISEASES. 

calcium  (chalk),  or  magnesia  or  lime  alone),  dissolved  in  or 
mixed  with  water,  will  be  suitable  as  an  antidote.  Oxalic  acid 
should  have  lime-water  freely  used  as  its  antidote.  2.  Alkalies ; 
e.g.,  caustic  potassa,  soda,  strong  solution  of  ammonia ;  earths, 
baryta,  lime.  For  these,  vinegar  or  lemon-juice  will  act  anti- 
dotally,  making  neutral  salts.  Olive  or  castor  oil  will  saponify 
the  alkaline  material,  and  thus  render  it  innocent.  3.  Corrosive 
Sublimate. — For  this,  whites  of  eggs,  or  wheat  flour  mixed  with 
water,  will  be  the  best.  4.  Arsenic. — Hydrated  peroxide  of  iron 
has  the  reputation  of  being  an  almost  certain  antidote  for  the 
common  arsenical  compound,  arsenious  acid  or  white  oxide  of 
arsenic.  It  may  be  made  fresh  by  adding  aqua  ammonice  to  liquor 
ferri  persulphatis,  or  aqua  ammonice  to  tincture  of  the  chloride  of 
iron.  It  is  well  for  every  physician  to  have  a  pint  of  each  of 
the  two  first-named  articles  always  within  reach.  The  precipi- 
tated hydrate  should  be  given  promptly  and  freely.  D.  C.  A. 
Leale,'  of  New  York,  has  found  the  common  suhcarhonate  of  iron 
to  answer  satisfactorily  in  several  serious  cases  of  arsenical  poi- 
soning. It  has  the  advantage  over  the  hydrated  oxide,  that  it  is 
more  commonly  to  be  found  on  hand  in  druggists'  establishments. 
Some  toxicologists  regard  magnesia  as  an  almost  equally  reliable 
antidote  for  arsenic,  5.  Sulphate  of  Copper ;  Salts  of  Tin.— 
"Whites  of  eggs,  milk,  or  flour  mixed  with  water  may  be  given 
freely.  6.  Tartar  Emetic. — Infusion  of  galls  or  oak-bark,  or 
tannic  acid  in  solution,  may  be  administered  copiously.  If  they 
are  not  obtainable,  strong  tea  may  be  substituted.  Afterwards 
opiates,  as  paregoric,  or  perhaps  an  enema  of  flaxseed  tea  and 
laudanum,  will  help  to  compose  the  stomach  and  bowels. 
7.  Acetate  of  Lead. — Sulphate  of  magnesium  is  antidotal  for 
this,  making  the  insoluble  and  inert  sulphate  of  lead.  8.  Sul- 
phate of  Iron  (green  vitriol) ;  Sulphate  of  Zinc  (white  vitriol) : 
Carbonate  of  sodium  is  recommended  for  these,  copiously  diluted. 
Flaxseed  tea  is  a  good  diluent  for  any  corrosive  poison.  9. 
Nitrate  of  Silver.— Common  salt  is  its  antidote,  making  chloride 
of  silver,  inert.  Drinking  milk  freely  will  also  aid  in  protecting 
the  stomach.  10.  Phosphorus. — A  mustard  emetic  may  be  the 
first  thing.  In  any  poisoning,  not  accompanied  by  vomiting  as 
an  effect,  this  will  be  proper.  Magnesia  and  mucilaginous  infu- 
sions may  then  be  given,  quickly  and  largely.'^  11.  Iodine. — 
Starch  neutralizes  iodine,  but  it  will  not  neutralize  iodide  of 
potassium,  for  which  no  strictly  chemical  antidote  is  known. 
12.  Creasote. — Whites  of  eggs,  or  milk,  or  flour  and  water,  will 
combine  with  it.  But  while  waiting  for  these,  free  draughts  of 
water  should  be  given.  For  carbolic  acid,  which  is  the  creasote 
of  coal-oil,  Messrs.  Calvert  state  that  olive  or  castor  oil  is  the 
best  antidote.  Glycerin  and  raw  eggs  will  also  help  to  dilute  or 
neutralize  it.  Saccharate  of  lime  is  said  by  Dr.  T.  Haseman  to 
be  an  antidote  for  carbolic  acid.  According  to  Baumann,  sul- 
phate of  sodium  (Glauber's  salt)  is  its  best  chemical  antidote, 
forming  an  innocuous  sulpho-carbolate. 

1  Am.  Journal  of  Med.  Sciences,  January,  1880. 

2  Letheby,  Audant,  and  Personne  are  reported  to  have  shown  that  oil  of  turpentine  i» 
an  antidote  for  phosphorus. 


POISONS.  5y7 

Narcotic  Poisons, — Opium.  When  any  such  poison  has  been 
takt'ii,  if  the  i)atiunt  can  swallow,  an  emetic  should  be  given;  ten 
grains  of  sulphate  of  copper,  twenty  grains  of  sulphate  of  zinc, 
half  a  teaspoonful  of  powder  of  ipecacuanha,  or  a  tablespoonful 
of  mustard,  either  dissolved  or  mixed  in  a  large  draught  of  warm 
water.  Vomiting  nmst  be  insured  by  repeated  doses.  If  swal- 
lowing be  impossible,  the  stoviach-pump  must  be  used  ;  introducing 
the  flexible  tube  through  the  pharynx  into  the  stomach,  and 
washing  it  out  by  gentl)'^  injecting,  and  then  withdrawing,  half  a 
pint  of  water  at  a  time  by  means  of  a  syringe. 

If  any  antidote  for  opium  or  its  alkaloids  has  given  reason  for 
confidence,  it  is  belladonna.  Facts  fully  warrant  its  administra- 
tion. Twenty  minims  of  tincture  of  belladonna  may,  in  opiate 
narcotism,  be  given  every  hour ;  perhaps  oftener.  Dr.  J.  Johnson, 
of  Shanghai,  after  a  very  large  experience  with  opium  poisoning 
in  China,  advises  hypodermically  injecting  half  a  grain  of  atropia; 
to  be  relocated  in  two  hours  if  it  has  failed  to  produce  dilatation 
of  the  pupils  and  tranquil  breathing.^  Smaller  quantities  injected 
at  shorter  intervals,  watching  the  effects,  are  safer.  Dilatation 
of  the  pupils  is  a  sign  of  the  constitutional  influence  of  bella- 
donna or  atropia.  Strong  coffee  is  an  older  remedy,  upon  a 
similar  indication.  To  counteract  the  comatose  tendency,  also, 
cold  water  may  be  dashed  or  poured  at  intervals  over  the  head 
and  face ;  strong  sinapisms  may  be  applied  to  the  back,  epigas- 
trium, and  limbs ;  or  the  patient,  if  able,  may  be  made  to  walk 
about ;  or  flagellation  with  a  hand  or  wet  towel  may  be  used  for 
the  same  end. 

In  the  extremest  cases  faradization  may  be  used ;  the  inter- 
rupted electrical  current  being  applied  to  the  spine  and  chest. 
Galvano-puncture  is  justifiable  if  other  means  fail ;  the  fine  needle 
being  made  to  penetrate  so  as  to  reach  the  diaphragm,  for  the 
immediate  stimulation  of  its  muscular  power.  The  needle  for 
such  a  purpose  should  be  of  soft-tempered  steel,  platinized ; 
fine  and  sound,  well-polished,  three  or  four  inches  long,  with 
a  lance-shaped  point.  Artificial  rcsjnration  is  resorted  to  in  some 
cases.  (See  Asphyxia.)  Dr.  Farnsworth,  of  Iowa,  has  used 
successfully  the  hypodermic  injection  of  diluted  aqua  ammonice; 
C.  Paul  and  Crequy,  inhalation  of  oxygen. 

Belladonna  or  atropna  may  be  antagonized  by  opium,  upon  the 
same  kind  of  evidence  as  that  just  alluded  to.  The  antidotal 
action  is  not  chemical,  but  physiological.  Dr.  H.  C.  Wood,  Jr., 
asserts  that  there  is  much  less  satisfactory  evidence  of  the  cura- 
tive influence  of  opium  in  poisoning  from  belladonna,  than  there 
is  of  the  converse  antagonism.  He  doubts  the  value  of  the 
former,  while  admitting  the  latter.  Grattan-  has  used  pnlocarpnn 
with  success.  Stramonium  (Jamestown  weed)  must  also  stand 
in  a  similar  relation  to  opium ;  and  so  may  hyoscyamus,  in  a  less 
positive  degree.  Atropia  is  also  a  physiological  antidote  for 
calabar-bean,  and  its  active  principle,  physostigmia.  Hydrate 
of  chloral  may  act  i)oisonously  in  doses  of  over  50  grains,    l^a 

1  London  Medical  Record,  April  9,  1873. 

2  Brit.  Med.  Journal,  April  16,  1881. 


588  UNCLASSIFIED    DISEASES. 

certain  antidote  is  yet  known  for  it.  An  emetic  or  stomach- 
pump  should  be  used,  and  strong  coffee  or  tea  may  then  be 
given,  freely,  till  the  respiration  becomes  normal.  Inhalation  of 
nitrate  of  amyl  is  said  to  have  power  as  an  antagonist  of 
chloral. 

Unclassified  Poisons.— Prussic  Acid.  For  this  no  certain 
antidote  exists ;  and  the  arrest  of  life  is  so  sudden  as  scarcely  to 
allow  its  use,  if  we  had  one.  T.  and  T.  C.  Smith,  English  chem- 
ists, assert  that  they  have  proved  the  following  recipe  to  be 
antidotal  for  it : — 

"Take  of  liquor  of  perchloride  of  iron  57  minims;  protosul- 
phate  of  iron  in  crystals,  pure,  25  grains  ;  as  much  water  as  will 
make  a  solution  of  a  proto-sesquisalt  of  iron,  measuring  about 
half  an  ounce.  Dissolve,  on  the  other  hand,  77  grains  of  crystal- 
lized carbonate  of  soda  in  about  half  an  ounce  of  water.  These 
quantities  destroy  the  poisonous  action  of  between  100  and  200 
drops  of  prussic  acid,  officinal  strength,  by  giving  first  the  one 
liquid,  and  then  the  other.  For  cyanide  of  potassium  the  antidote 
is  the  same,  except  that  the  solution  of  proto-sesquisalt  of  iron 
is  to  be  used  without  the  soda  solution ;  the  hydrocyanic  acid 
having  been  already  combined  with  an  alkaline  substance.  The 
use  of  the  soda  would,  however,  not  be  injurious.  The  quan- 
tities given,  as  above,  would  decompose  35  grains  of  cyanide  of 
potassium." 

Gold  affusion,  chlorine  water,  and  ammonia,  are  the  older  meas- 
ures advised  for  prussic  acid  poisoning. 

Aconite,  digitalis,  hemlock,  ergot,  tobacco,  lobelia,  veratrum  viride, 
aniline,  strychnia,  cantharides,  gelsemium,  poisonous  fungi,  etc., 
have  no  known  certain  antidotes.  Emetics  should  be  promptly- 
given  when  any  of  them  are  known  to  have  been  taken.  Castor 
oil  is  also  recommended,  especially  for  those  least  depressing  in 
their  action.  Aconite,  lobelia,  and  tobacco  are  the  most  power- 
fully sedative.  Ati'opia  is  antagonistic  to  muscarin,  the  active 
principle  of  poisonous  mushrooms  (toadstools).  Animal  char- 
coal is  advised,  to  absorb  and  render  innoxious  organic  poisons 
in  the  stomach;  teaspoonful  doses  should  be  given  repeatedly. 
For  the  spasms  caused  by  strychnia  or  nux  vomica,  inhalation  of 
chloroform  is  thought  to  be  beneficial.  Hydrate  of  chloral  has 
sometimes  succeeded  in  relieving  them.  For  tobacco,  lobelia, 
aconite,  digitalis,  or  veratrum  viride  taken  poisonously,  brandy  or 
whisky  as  a  stimulant  would  seem  to  be  indicated. 

Cantharides,  gelsemium,  and  poisonous  fungi  (toadstools,  etc.), 
all  being  irritants,  after  vomiting  has  been  produced,  besides 
castor  oil,  demulcent  drinks  may  be  given ;  as  flaxseed  tea,  infu- 
sion of  gum  arabic,  etc. ;  with  moderate  doses  of  some  opiate,  by 
the  mouth  or  rectum. 

Bromide  of  potassium  has  been  used  successfully  as  an  anti- 
dote to  strychnia,  by  Drs.  Gillespie,  Baird,  and  Bates.  (See  Am, 
Journal  of  Med,  Sciences,  October,  1870  ;  and  Philada.  Med. 
Times,  June  1,  1871.)  S.  Buckley  obtained  recovery  in  one  case 
of  strychnia  poisoning  by  the  hypodermic  injection  of  atropia. 
See  Edinburgh  Med.  Journal,  September,  1873.  Hydrate  of 
chloral  and  coffee  are  both  antagonistic  to  strychnia  ;  and  so  is 


BITES    OF    SERPENTS.  589 

digitalis  to  aconite.     Iodine  and  tannin  are  both  antidotal  to 
strychnia  ;  and  pilocarpin  to  atropia. 

Muridte  of  apomorplda  was  nsed  with  success  in  a  case  of  strych- 
nia poisoning  b)'  Dr.  Glisan,'  of  Oregon,  in  1877,  One-third  of  a 
grain  (a  large  dose)  was  injected  hypoderniically  ;  producing  vom- 
iting and  relief  of  the  spasms,  followed  by  recovery. 

BITES  OF  SEEPENTS. 

When  a  person  is  bitten  by  a  venomous  serpent,  or  by  a  rabid 
dog  or  other  animal,  the  part  should  l)e,  if  accessible,  at  once 
trucked  strongly  with  the  mouth,  to  avoid  loss  of  time.  Although 
it  has  been  shown  that  the  vc^nom  of  serpents  is  not  (as  has  gen- 
erally been  asserted)  innocuous  when  swallowed,  yet,  in  the 
absence  of  excroriation  about  the  mouth,  it  may  be  safely  with- 
drawn b}'  suction  and  at  once  ejected.  Wash  the  wound  then 
thoroughly  with  hot  water.  Apply  a  cupping-glass  for  some  min- 
utes. Cauterize  it  with  red-hot  iron  or  caustic  potassa  ;  or  car- 
bolic acid,  with  one-half  its  bulk  of  alcohol  ;  or  if  practicable,  excise 
the  part  bitten.  When  this  cannot  be  done,  and  while  waiting 
for  it,  in  all  cases,  a  tight  ligature  may  be  applied  to  retard 
absorption.  Aqua  ammonicB  has  been  thought  useful  also  as  a 
local  antidote  for  snake  poison,  as  it  is  for  that  of  venomous 
insects  ;  and  so  has  fluid  extract  of  f^erpentaria.'^  The  leaves  of 
anantherix  decicmbens  are  used  with  confidence  in  Mexico  as  a 
local  application  for  rattlesnake  bites.  The  careful  experiments 
of  Dr.  8.  Weir  Mitchell  throw  great  doubt  over  the  value  of  all 
asserted  antidotes  for  the  poison  of  the  rattlesnake.  He  has 
shown,  however,  that  a  small  amount  of  the  venom  is  often  intro- 
duced, without  fatal  effect ;  the  danger  depending  on  its  quantity. 

Should  symptoms  of  poisoning  have  already  followed  the  bite 
of  a  rattlesnake,  experience  seems  to  countenance  the  antag- 
onistic and  supporting  use  of  whisky.  Cures  are  said  to  have 
occurred  in  several  instances,  when  the  person  bitten  drank  large 
amounts  of  this  ;  intoxication  not  being  produced,  on  account  of 
the  counterr,cting  impression  of  the  poison  upon  the  system. 
One  case  of  recovery  after  rattlesnake  bite  has  been  reported 
( Medical  Record^  August  1,  1871)  under  five  twenty-grain  doses 
of  chloral  hydrate. 

Prof.  Halford,  of  Melbourne,  Australia,  reports  the  recovery 
of  17  out  of  20  cases  of  venomous  snakebite,  after  the  injection 
of  30  minims  of  liquor  ammonise  (diluted,  1  part  to  3  of  water) 
with  a  hypodermic  syringe,  into  a  superficial  vein.  Five  other 
Australian  physicians  confirm  his  statements  v''  although  less  suc- 
cess has  so  far  attended  the  same  treatment  elsewhere.  Dr. 
Fayrer,  with  a  large  experience  in  India,  has  found  it  to  fail 
altogether ;  possibly  because  some  Indian  serpents  may  be  more 

1  Amer.  Journal  of  Med.  Sciences,  April,  1878,  p.  44S. 

2  Bibron's  antidote  consists  of  bromine,  5ijss ;  ioflids  of  potassium,  gr.  ij  ;  corrosive 
sublimate,  gr.  j;  dilute  alcohol,  f.>xxx.  Dose,  f5.j,  in  wine  or  brandy,  p.  r.  n.  Lini''- 
water  is  asserted  by  Dauvernc  to  give  immediate  relief  to  the  pain  caused  by  the  stings 
of  bees  and  wasps.     Aqua  nmmimifriwxW  generally  arrest  the  pain  of  bee-stings  at  once. 

3  N'l.'iirc.  Sept.  .S,  1870  Th  •  .serpents  were  the  very  venomous  tiger-snake  and  brown 
and  l)lack  snakes  of  Australia. 

50 


590  UNCLASSIFIED    DISEASES. 

fatally  venomous  than  those  of  Australia.^  Inspector-General 
C.  J.  Smith, ^  of  Madras,  has  recorded  the  cure  of  a  case  of  cobra 
poisoning,  by  the  internal  use  of  liquor  ammonise,  in  half-drachm 
doses,  diluted,  taken  repeatedly  every  ten  or  fifteen  minutes. 
Dr.  Fayrer  has  more  confidence  in  artificial  respiration,  in  bad 
cases,  than  in  any  other  remedy  ;  but  the  cobra  bite,  esi^ecially 
in  vascular  parts  of  the  body,  is  apt  to  be  incurably  fatal.  So  is 
that  of  the  rattlesnake,  and  of  the  moccasin  of  the  Southern 
States,  about  the  face  or  neck ;  as  well  as  that  of  the  phoorsa 
snake. 

ASPHYXIA. 

"Whether  from  drowning,  breathing  coal-gas  in  an  unventilated 
apartment,  or  excessive  inhalation  of  chloroform,  etc.,  the  treat- 
ment for  suspended  animation  must  be  essentially  the  same  in 
principle.  First  loosen  everything  about  the  neck.  Draw  the 
tongue  forward  and  clear  the  mouth.  Laying  the  patient  upon 
the  back,  let  both  arms  be  raised  (Sylvester)  as  far  as  possible 
above  the  head,  and  then  brought  down  again ;  this  should  be 
repeated  at  least  fifteen  or  twenty  times  a  minute.  Pacini's 
method  of  drawing  the  shoulders  upward,  and  Bain's  of  lifting 
and  letting  them  down  alternately,  may  be  combined  with  Syl- 
vester's. Blowing  into  the  mouth  or  nostrils,  with  or  without 
a  trachea-tube  or  a  quill  in  the  nostril,  is  available  sometimes, 
especially  in  a  child ;  at  the  same  time,  when  oxygen  gas  can  be 
obtained  (as,  of  course,  it  very  rarely  can),  a  jet  of  it  may  be  used. 

Dr.  Polk,^  of  New  York,  in  1880,  saved  a  child's  life  by  intro- 
ducing into  its  larynx  through  the  glottis  a  'No.  8  silver  catheter, 
and  inflating  the  lungs  by  blowing  through  it ;  an  assistant  alter- 
nating this  with  pressure  upon  the  chest  and  abdomen  to  pro- 
mote expiration.  Le  Bon  and  Goyard*  have  found  immersion  in 
hot  water  effective  in  relieving  the  asphyxia  of  new-born  infants. 

Passing  a  vial  of  solution  of  ammonia  at  intervals  under  the 
nostrils  will  aid  to  excite  the  nerve-centres.  Rubbing  the  limbs 
and  trunk  vigorously,  and  chiefly  towards  the  heart,  to  hurry  the 
venous  circulation,  is  useful.  So,  also,  is  the  application  of  mus- 
tard, or  friction  with  red  pepper  and  brandy  or  whisky.  Hot 
bottles  may  be  applied  to  the  feet  and  legs.  Excessive  heat  will 
not  be  expedient  before  respiration  is  established  ;  but  moderate 
warmth  always  promotes  vitality.  The  application  of  a  red-hot 
iron,  momentarily,  to  the  epigastrium  or  the  back  of  the  neck, 
for  intensely  stimulant  effect,  is  not  unreasonable  in  idea.  Gal- 
vanism may  be  employed  in  any  case  of  suspended  animation. 
The  extraordinary  measure  has  recently  been  sometimes  prac- 
tised, of  forcibly  dilating  the  anus  and  introducing  the  hand  and 
forearm  into  the  bowel,  as  far  as  the  colon.  The  semi-lunar 
ganglia,  it  is  believed,  may  be  thus  subjected  to  stimulation  by 
contact.     Atropia,  hypodermically  injected,  as  a   "respiratory 

1  In  1871,  Dr.  Halford  received  thanks  from  the  Government  of  India  for  the  intro- 
duction of  this  treatment;  and  the  republication  of  his  pamphlet,  for  distribution,  was 
oflncially  ordered.  Of  939  cases  of  snake-bite  treated  in  Bengal  by  the  police,  with 
ammonia,  702  are  said  to  have  recovered. 

2  Brit.  Med.  Journal,  Feb.  22,  1868. 

3  N.  Y.  Medical  Record,  June  19,  1880,  p.  710. 
*  Le  Courrier  Medical,  Jan.  22,  1881. 


ASPHYXIA.  591 

stimulant "  is  recommendod  by  some  authorities  in  asphyxia  •, 
and  digitalis,  similarly  used,  as  a  "cardiac  stimulant." 

The  Executive  Committee  of  the  Life  Saving  Society  of  New 
York,  consisting  of  Prof.  Frank  II.  Hamilton,  Prof.  C.  F.  Chand- 
ler, and  others,  have  issued  the  following  series  of  rules  for  the 
treatment  of  persons  rescued  from  tiie  water  in  an  insensible 
condition : — 

"Rule  1. — To  drain  ofl' water  from  chest  and  stomach:  Instantly 
strip  the  patient  to  the  waist.  Place  him  face  downward,  the 
pit  of  the  stomach  being  raised  above  the  level  of  the  mouth  by 
a  large  hard  roll  of  clothing  placed  beneath  it.  Throw  your 
weight  forcibly  two  or  three  times,  for  a  moment  or  two,  upon  the 
patient's  I)ack,  over  a  roll  of  clothing,  so  as  to  press  all  tluids  in 
the  stomach  out  of  the  mouth.  ^ 

"Rule  2. — To  perform  artificial  breathing:  Quickly  turn  the 
patient  upon  his  back,  the  roll  of  clothing  being  so  placed  beneath 
as  to  make  the  breastbone  the  highest  point  of  the  body. 

"  Kneel  1)eside  or  astride  patient's  hips.  Grasp  the  fnmt  part  of 
the  chest  on  either  side  of  the  pit  of  the  stomach,  resting  your 
fingers  along  the  spaces  between  the  short  ribs.  Brace  your 
elbows  against  your  sides,  and  steadily  grasping  and  pressing  for- 
ward and  upward,  throwing  5^our  whole  weight  upon  your  chest, 
and  gradually  increasing  the  pressure  while  you  can  count  one, 
two,  three.  Then,  suddenly,  let  go  with  a  final  push,  which 
springs  you  back  to  your  first  position.  Rest  erect  upon  your 
knees  while  you.  can  count  one,  two  ;  then  make  pressure  again 
as  before,  repeating  the  entire  motions  at  first  about  four  or  five 
times  a  minute,  gradually  increasing  to  about  ten  or  twelve  times. 

"  Use  the  same  regularity  as  in  blowing  bellows,  and  as  is  seen 
in  natural  breathing,  which  you  are  imitating. 

"  If  another  person  be  present,  let  him,  with  one  hand,  by  means 
of  a  dry  piece  of  linen,  hold  the  tip  of  the  tongue  out  of  one  corner 
of  the  mouth,  and,  with  the  other  hand,  grasp  both  wrists  and 
pin  them  to  the  ground  above  the  patient's  head." 

Having  witnessed,  in  two  cases  at  Atlantic  City,  the  insuffi- 
ciency of  the  above  methods  of  producing  artificial  respiration, 
it  has  occurred  to  me  that  ahdomiwd  insjoiration  may  perhaps  be 
promoted,  by  vigorous  traction  upon  the  walls  of  the  abdomen. 
I  have  had  made  an  instrument  for  such  action ;  consisting  of  a 
large  syringe  or  pump,  about  two  inches  in  diameter  and  twelve 
inches  long,  attached  to  a  metallic  cup  or  bowl,  six  inches  across 
at  its  outer  edge.  It  is  intended  to  be  applied  closely  to  the 
uncovered  abdomen,  so  that,  by  strong  traction  with  the  pump, 
the  viscera  may  be  lifted  and  the  diaphragm  made  to  descend. 
I  have  not  yet  had  opporti;nity  to  make  trial  of  this  method  ;  but 
it  appears  to  me  that  it  ought  at  least  to  answer  the  purpose  of 
facilUating  the  action  of  the  diaphragm.  It  may  be  readily  com- 
bined with  Sylvester's  method,  as  above  described.^ 

After-treatment. — After  breathing  has  become  natural,  dry  the 
patient  briskly.     Wrap  him  in  blankets  only  and  let  him  be  kept 

1  Of  course  violence  must  be  avoided  in  such  a  procedure. 

2  The  same  principle,  of  a6rfo»wno/ /r«c<i07j,  was  applied  many  years  a.a;o  by  Kuck  to 
the  treatment  of  obstruction  of  the  bowels.  My  instrument  may  probably  prove  useful 
in  that  iiffection,  as  well  as  in  the  reduction  of  strangulated  inguinal  hernia,  prolapsed 
ovary,  etc. 


592  UNCLASSIFIED    DISEASES. 

perfectly  quiet.  Provide  free  circulation  of  air.  Give  brandy 
and  water — a  teaspoonful  every  five  minutes  the  first  half  hour, 
and  afterwards  occasionally  as  may  seem  expedient. 

EYESIGHT:  ITS  EXAMINATION  AND  CORRECTION. 

Ophthalmic  surgery  has  become,  of  late  years,  more  and  more 
a  specialty.  Yet  it  is  desirable  for  the  general  practitioner  to 
know  at  least  when,  and  why,  it  is  best  to  refer  a  patient  to  an 
oculist  for  treatment.  In  some  localities,  moreover,  this  cannot 
well  be  done,  and  the  physician  must  then  do  his  best  without 
special  assistance. 

An  outline  of  the  subject  may  therefore  here  be  proper,  refer- 
ring the  reader  to  extended  treatises  for  fuller  information.^ 

Sight  may  be  deficient  from  many  causes:  congenital  inca- 
pacity (a  variety  of  which  is  color  blindness)  ;  amaurosis  (optic 
nerve-paralysis)  ;  cataract  (opacity  of  the  lens  or  its  capsule) ; 
corneal  opacity  ;  turbidity  of  the  vitreous  humor ;  disorganiza- 
tion of  the  retina,  and  errors  of  visual  refraction. 

Our  space  does  not  allow  us  to  dwell  here  upon  any  of  these 
except  the  last.    (See  Ophthalmoscope,  under  Semeiology,  in  Part  I.) 

In  a  normal,  perfect  eye,  parallel  rays  of  light  are  brought  to 
a  distinct  focus  upon  the  retina.  Approximately,  the  sun's  rays 
may  be  regarded  as  parallel ;  and  so,  practically,  for  the  purposes 
of  vision,  are  rays  coming  from  an  object  at  a  distance  of  twenty 
feet  or  more.  The  eyes  are  at  rest  when  looking  at  anything 
beyond  that  distance  ;  most  completely  so,  when  we  look  at  the 
sky  or  at  a  far  off  landscape. 

As  rays  of  light  from  a  near  object  diverge  considerably,  in 
order  for  them  to  be  focussed  upon  the  retina  and  make  a  cleat 
image,  the  eye  must  be  adjusted  to  them  by  increase  of  the  con- 
vexity of  the  crystalline  lens.  This  is  effected  by  the  ciliary 
muscle  ;  and  the  adjustment  resulting  is  called  accommodatioii. 
Also,  in  looking  at  a  near  object,  in  order  that  both  eyes  may 
give  one  image,  they  must  converge,  so  that  the  visual  axes  of 
the  two  eyes  would,  if  prolonged,  meet  in  the  object.  This  con- 
vergence is  produced  by  the  joint  action  of  the  two  internal  recti 
muscles.  These  muscular  actions  are  sensori-motor ;  the  efierent  or 
motor  nerve,  both  for  accommodation  and  convergence,  being  the 
third  cephalic  nerve.  These  two  changes,  normally  and  usually,  ■ 
occur  together ;  and  any  disruption  of  their  harmony  occasions 
pain  and  other  symptoms,  constituting  muscular  asthenopia. 

Near  vision  always  has  a  limit,  beyond  which  accommodation 
cannot  go.  At  10  years  of  age,  this  may,  in  healthy  eyes,  be 
somewhat  less  than  3  inches.  Chiefl}^  from  diminishing  elas- 
ticity of  the  lens,  the  "near  point"  gradually  recedes.  At  20 
years,  it  may  be  scarcely  less  than  4  inches ;  at  40,  about  7 
inches  ;  at  50,  12  inches ;  and  at  60,  two  feet.  For  reading 
ordinary  type,  good  adult  eyes  have  a  range  of  from  seven  inches 
to  about  three  feet.  For  total  vision,  the  range  with  such  eyes 
is  from  the  near  point  to  the  most  distant  fixed  star.  A  good 
distance  for  reading  is  18  inches. 

1  See  Lawrence  and  Moon,  R.  B.  Carter,  ,T.  Soelberg  Wells,  or  E.  Nettleship,  on  Oph- 
thalmic Surgery ;  Browne  on  the  Ophthalmoscope,  etc. 


EYESIGHT.  593 

Emmetropia  is  the  normal  condition  of  the  refractinej  media 
of  the  eye  ;  in  which  parallel  rays,  or  those  api)roximately  so, 
from  distant  objects,  come  to  a  focus  upon  the  retina.  Devia- 
tions from  this  are  different  forms  of  ametropicL 

Hypermetropia  is  that  form  of  error  of  refraction,  or  ametro- 
pia, in  which,  from  too  gi'eat  flatness  or  (antero-posterior)  short- 
ness of  the  eye-ball,  parallel  rays  come  to  a  focus  beliind  the  retina  ; 
making  thus  a  confused  image,  unless  the  fixult  be  corrected. 

Myopia,  or  near-sightedness,  is  caused  by  too  great  convexity 
of  the  crystalline  lens,  or  more  frequently,  excessive  length  of  the 
eye-l)all ,  parallel  rays  being  thus  brought  to  a  focus  in  front  of 
the  retina.  Diverging  rays  from  a  near  object  have  their  focus 
thrown  farther  back,  so  that  at  a  certain  degree  of  approach 
they  form  an  image  upon  the  retina,  giving  distinct  vision. 
High  degrees  of  myopia  render  it,  without  artificial  aid,  impos- 
sible to  see  anytliing  clearly,  except  within  a  few  inches  of  the 
eye.  A  range,  however,  generally  exists,  of  a  few  inches  at  least, 
between  the  myopic  far  point  of  vision,  and  a  near  point,  toward 
and  to  which  accommodation  can  be  effected. 

Hypermetropic  eyes  have  to  be  adjusted  (accommodated)  even 
for  remote  objects  ;  and  more  and  more  so  as  they  are  nearer. 
"With  them,  accommodation  is  in  excess  of  convergence. 

Myopic  eyes,  on  the  contrary,  as  they  only  see  clearly  things 
which  are  brought  near  to  them,  have  their  convergence  in  excess, 
often  greatly,  of  their  accommodation.  In  both  of  these  cases, 
the  want  of  harmony  between  the  two  sets  of  co-ordinate  mus- 
cles (ciliaris  and  internal  recti)  is  a  frequent  cause  of  distress. 
Fatigue  of  the  eyes,  pain,  dimness  of  vision,  congestion  of  the 
eye-ball,  and,  sometimes,  dizziness,  headache,  and  other  sympa 
thetic  nervous  symptoms,  are  thus  produced. 

Presbyopia  is  the  natural  change  in  the  eyesight  accompany- 
ing advancing  years.  Between  40  and  45  years  of  age,  usually, 
the  lens  grows  firmer  and  flatter ;  so  that  accommodation  for 
near  objects  (as  in  reading)  is  difficult  and  imperfect.  Later,  or 
even  at  about  the  same  period,  the  ciliary  muscle  shares  the  loss 
of  energy  of  the  general  muscular  system  of  the  body  ;  and,  also, 
the  sensitiveness  of  the  retina  to  visual  impressions  grows  less 
and  less  with  increasing  age.  It  is  to  senile  defective  accommoda- 
tion for  near  objects,  often  with  little  or  no  change  in  regard  to 
those  at  a  distance,  that  the  term  presbyopia  is  especially  applied. 

Astigmatism  is  produced  by  a  difference  in  the  curve  of  differ- 
ent parts  of  the  cornea,  or,  sometimes,  of  the  crystalline  lens. 
The  bowl  of  a  spoon  exemplifies  a  rounded  surface  in  which  the 
curve  in  one  "meridian"  is  longer  than  that  in  the  other. 
This  difference  (a  slight  degree  of  which  is  present  in  almost  all 
eyes)  produces  less  distinctness  of  vision  of  lines  or  forms  extend- 
ing in  the  direction  of  one  of  the  two  unequal  curves.  A  person 
with  astigmatism  may  be  myopic  for  horizontal  lines,  and  emme- 
tropic or  hypermetropic  for  those  whieh  are  vertical ;  or  the  same 
error  of  refraction  may  exist  for  both  meridians,  but  in  difterent 
degrees.  Sometimes  the  axes  of  the  unlike  curvatures  are 
oblique^  instead  of  horizontal  and  vertical  ;  but  they  are  always 
at  right  angles  to  each  other. 

50  *  2  N 


594  UNCLASSIFIED    DISEASES. 

Asthenopia  is,  literally,  weakness  of  sight„  It  is  of  two  kinds 
or  origins,  often  combined  :  muscular  {my asthenopia)  and  nervous 
{neur asthenopia).  The  attention  of  oculists  has  been  almost  exclu- 
sively devoted  to  the  former ;  but  the  latter  also  is  important.^ 
Muscular  asthenopia  results  mainly  from  discordant  action  (above 
alluded  to)  between  the  two  acts  of  accommodotion  and  conver- 
gence, A  near-sighted  person,  for  example,  requires  a  great  deal 
of  convergence  of  the  eyes,  to  look  at  an  object  close  to'his  face  ; 
while  his  accommodation,  at  the  far  point,  is,  or  may  be,  nil; 
and  it  is,  at  any  point,  much  less  than  his  convergence.  The 
reverse  occasion  of  discord  exists  in  hypermetropic  eyes  ;  accom- 
modation being,  with  them,  in  excess  of  convergence.  Either 
way,  uncorrected  vision,  especially  when  attempting  continued 
reading,  or  fine  work  of  any  kind,  causes  distress,  fatigue,  and 
dimness  of  vision.  Not  very  rarely,  symptoms  of  general  indis- 
position, perhaps  simulating  brain  disease,  are  thus  originated  ; 
their  source  in  the  eyes  being  shown  by  the  relief  at  once  afforded 
by  properly  adjusted  glasses.  In  nervous  asthenopia,  the  optic 
nerve,  its  ganglia,  or  the  retina,  or  all  these  together,  are  at  fault. 
In  this  form,  rest  to  the  eyes  from  all  work  is  commonly  the  most 
essential  remedy.  With  the  more  frequent  muscular  asthenopia, 
from  errors  of  refraction,  rest  gives  only  a  partial  and  temporary 
renef ;  the  true  remedy  for  it  is  proper  correction  of  the  visual 
defect  by  glasses  adapted  to  it. 

Strabismus  (squint,  or  cross-eyes)  is  an  obvious  defect,  from 
the  overaction  of  either  the  internal  (convergent)  or  external 
(divergent)  recti  muscles.  Double  vision  must  result  from  it. 
Practically,  however,  in  cases  of  permanent  or  long  continued 
strabismus,  the  mind  becomes  accustomed  to  attend  to  only  one 
of  the  images  seen  ;  so  that  the  inconvenience  is  less  than  might 
be  expected.  To  correct  this  deformity,  the  stronger  rectus 
muscle  is  sometimes  divided  by  the  surgeon. 

Diagnosis. — First,  it  is  always  desirable  to  ascertain  the  acuteness 
of  vision  of  the  patient  examined.  For  this,  Jager  devised  test- 
ttjpes  to  be  read  at  a  definite  distance.  They  run  from  1  to  20; 
the  two  extremes  being  these  i 

BrilUiUt,  &,  b,  c,  d,  «,  f,  g,  h.  i,  J,  k,  1.  m,  o.  o,  p,  q.  r.  s,  t,  n,  T.  w,  s,  j,  s. 


1  Dr.  John  Green  (Carter  on  the  Eye,  Amer.  edition,  p.  448,  note)  writes  thus :  "  There 
is  unfortunately  a  very  considerable  class  of  asthenopia  cases  whose  chief  characteristic 
is  discomfort  or  pain  in  usins  the  eyes,  in  the  treatment  of  which  spectacles  eithov 
afford  no  relief  or  play  a  comparatively  unimportant  part." 


EYESIGHT.  595 

Snellen's  types  are  more  scientifically  contrived  for  exsict  com- 
parison of  visual  acuteness.  They  are  square  letters,  the  limbs  and 
subdivisions  of  which  are  measured  to  fifth  parts  of  their  height. 
They  are  numbered  according  to  the  distance,  in  Paris  feet,'  at 
which  a  normal  eye  can  read  them  distinctly.  Thus,  No.  XX,  or 
20,  can  be,  or  ought  to  be,  read  at  the  distance  of  twenty  feet  ; 
No.  XL,  or  40,  at  forty  feet,  and  so  on.  The  following  are  taken 
from  a  set  of  test-types  modified  from  Snellen's  by  Dr.  J.  Green. '^ 


N 


20  8 

A  person  with  deficient  sight  may  be  able,  at  twenty  feet,  to 
distinguish  only  the  letter  which,  with  perfect  vision,  he  should 
read  at  forty  feet.  His  vision  is  then  but  |^-  or  |  of  normal  sight. 
Or,  at  ten  feet,  he  may  read  only  the  letter  which  should  be  legi- 
ble at  two  hundred  feet.  His  vision  is,  then,  -^  or  ^q.  This  is 
often  exjiressed  (V  indicating  visual  acuteness)  V=^^;  or, 
abridged,  V=  ^.     In  perfect  vision,  V=  fg  or  1. 

Near-sighted  persons  may  be  able  to  see  nothing  at  all  clearly 
at  a  distance  of  ten  feet.  For  these,  test-types  are  procurable 
from  opticians  (and  from  some  booksellers)  which  can  be  held  in 
the  hand  and  used  at  short  distances. 

In  the  absence  of  test-types,  a  rough  determination  of  visual 
acuteness  may  be  made  by  trying  at  what  distance  a  patient  can 
count  the  number  of  fingers  held  up  between  him  and  the  window 
or  some  other  sufficient  light. 

More  exact  examination  of  the  refraction  of  the  eyes  is  to  be 
effected  by  testing  them  with  lenses.  These  are  distinguished 
according  to  their  focal  length,  in  inches.  A  convex  lens  whose 
focus  for  parallel  (or  solar)  rays  is  twelve  inches  from  it,  is  said 
to  have  a  power  =  +  r?  ;  one  twice  as  strong,  bringing  parallel 
ra3's  to  convergence  at  half  the  distance,  ^  -{-  4^.  A  concave  lens, 
which  causes  parallel  rays  to  diverge  as  though  they  proceeded 
from  a  point  12  inches  in  front  of  it,  is  described  as  —  -^^  if  six 
inches, —  ^.  The  +  and  —  signs  are  thus  convenient  to  discrim- 
inate between  convex  and  concave  glasses.^ 


1  A  Paris  foot  is  a  little  more  than  12%  of  our  inches. 

2  (.'arter  on  the  Eye,  Amer.  edition. 

3  Cases  of  lenses  assorted  for  such  examinations  are  prepared  and  sold  by  several 
dealers. 


596  UNCLASSIFIED    DISEASES. 

Myopia  is  measured  by  the  power  of  the  concave  lens  required 
to  afford  distinct  vision  of  distant  objects.  If  a  lens  having  a 
power  of  —  ^^  (that  is,  causing  the  rays  of  liglit  passing  through 
it  to  diverge  as  if  from  a  point  12  inches  from  it)  will  correct  the 
myopia,  this  is  described  as  M=^.  Greater  degrees  are  ex- 
pressed by  the  fractions  |-,  ^  ;  lesser,  -^q,  •^,  etc. 

Hypermetropia  is  estimated  by  the  power  of  the  strongest  con- 
vex lens  through  which  vision  of  objects  at  a  distance  is  distinct 
and  comfortable  to  the  eye.  (In  all  these  examinations,  the  sight 
of  each  eye  should,  for  a  complete  diagnosis,  be  tested  separately.) 
As,  however,  the  effort  of  accommodation  habitually  corrects 
a  part  of  the  hypermetropic  error  of  refraction,  that  part  is  said 
to  be  latent,  and  that  discovered  by  the  correction  of  the  lens  is 
called  manifest  hypermetropia.  To  ascertain  the  total  error,  the 
ciliary  muscle  must  be  paralyzed  by  the  use  of  atropia.  This,^ 
however  (as  well  as  testing  the  muscular  convergence  by  prismatic 
glasses),  may  be  left  to  specialists  ;  since  correction  of  the  mani- 
fest hypermetropia,  with  glasses  progressively  adapted  to  the 
comfort  of  the  wearer,  will  usually  answer  every  practical  pur- 
pose. .  Formulse  descriptive  of  degrees  of  hypermetropia  are 
written  thus  :  H  =  ^,  is  that  degree  in  which  a  convex  lens  of 
45  inches  focal  length  will  give  satisfactory  correction.  Often  it 
goes  as  far  as  H  ==  j^g- ;  sometimes  -J ,  or,  rarely,  |  or  J.  If  com- 
fortable vision  is  not  obtained  by  either  concave  or  convex 
glasses,  astigmatism  may  be  suspected.  This  is  best  detected  and 
defined  by  the  use  of  letters  such  as  those  contrived  by  Dr.  O.  M. 
Pray,  of  Kew  York,  a  selection  from  which  is  here  presented. 


Horizontal.  so"  ^o  /20° 


If  a  letter  made  with  horizontal  lines  looks  clear  and  dark, 
while  one  with  the  lines  vertical  is  more  indistinct,  the  eyes  are 
(or  the  eye,  if  single,  is)  ametropic  in  the  vertical  meridian,  and 
vice  versa.  To  ascertain  whether  the  ametropia  is  myopjic  or 
hypermetropic,  we  must  find  whether  a  concave  or  a  convex  lens 
will  afford  it  correction.  Cylindrical  lenses  are  used  for  correc- 
tion of  astigmatism  ;  as  will  be  again  said  presently 

When  defective  vision  remains  which  is  not  accounted  for  by 
any  of  these  errors  of  refraction,  its  origin  or  nature  will  have  to 
be  ascertained  by  the  aid  of  the  ophthalmoscope,^  along  with  a 

1  If  used,  one  drop  of  a  solution  of  sulphate  of  atropia,  4  grains  to  fsj,  maybe  inserted 
between  the  lids  two  or  three  times,  an  hour  apart;  leaving  two  hours  after  the  last 
insertion  before  the  examination.  As  the  disturbance  of  vision  produced  by  atropia 
does',  not  go  off  for  four  or  five  days,  it  should  be  explained  to  the  patient,  and  he 
should  be  provided  with  convex  glasses  to  use  during  that  interval. 

2  The  ophthalmoscope  will  also  aid  or  confirm  the  diagnosis  of  errors  of  refraction. 
In  myopia  of  high  degree,  for  example,  an  inverted  image  can  be  obtained  without  the 
Intervention  of  an  object  lens.    Other  appearances  also  are  distinctive. 


EYES  I  OUT.  597 

careful  inquiry  into  the  whole  history  and  semeiolo<i;y  of  the  case. 
Two  groups  of  cases  (F(')rster)  are  likely  to  be  met  with  :  1.  Optic 
neuritis,  retinitis,  retinal  degeneration  of  Bright's  disease,  hemio- 
pia  of  cerebral  apoplexy,  and  impaired  vision  from  alcoholism. 
2.  Syphilitic  choroiditis,  pigmentary  retinitis,  and  detachment 
of  the  retina.  (For  the  further  study  of  these,  see  works  on  the 
Ophthalmoscope,  as  well  as  upon  Ophthalmic  Surgery.) 

Correction. — Commonest  and  simplest  of  all,  is  the  case  of 
preshifopia.  The  elderly  person  finds  it  difficult  to  read  or  see  to 
do  fine  near  work  ;  while  his  view  of  objects  at  a  distance  is 
unchanged,  at  least  until  quite  advanced  age.  His  accommoda- 
tion, for  near  vision,  needs  to  be  helped  or  substituted  by  convex 
glasses.  It  is  a  mistake  to  postpone  using  these,  after  any  strain 
is  felt  m  reading  without  them.'  At  first  they  may  be  needed 
only  in  reading  fine  print,  or  by  artificial  light  at  night ;  later 
(as  presbyopia  is  gradually  progressive)  at  all  times  in  reading. 
They  should  not  (if  there  is  no  other  error  of  vision)  be  used  in 
looking  at  distant  objects.  If  the  glasses  are  not  too  high  on  the 
nose,  they  may  be  looked  over  when  the  eyes  are  lifted  from  the 
book  or  near  work.  Sometimes  the  upper  half  of  each  glass  is 
removed  for  the  same  purpose  ;  but  that  is  not  necessary.  Too 
strong  glasses  strain  the  eyes,  and  should  not  be  worn  ;  but  it  is 
worse  to  withhold  sufficient  aid  to  the  eyes  when  it  is  needed. 

As  the  convex  lenses,  by  furnishing  or  substituting  accommo- 
dation, enable  the  presbyopic  person  to  bring  objects  near  to  his 
eyes,  this  demands  convergence,  without  corresponding  action  of 
the  accommodating  ciliary  muscle.  This  may  cause  discomfort 
from  incoordination  of  the  tw^o  sets  of  ocular  muscles.  There- 
fore, when  simple  convex  glasses  do  not  work  satisfactorily,  pris- 
matic lenses  may  be  added  to  relieve  the  convergence. 

A  prism  (being  virtually  one  side  or  section  of  a  convex  or  con- 
cave spherical  lens)  shifts  the  direction  of  vision  through  it 
towards  the  side  on  which  the  edge  of  the  prism  is  placed ;  and 
more  or  less  so,  according  to  the  angle  at  which  the  sides  of  the 
prism  meet.  If  the  edge  of  the  prism,  placed  before  the  eye,  is 
outward,  the  base  being  inward,  the  axis  of  vision  is  moved 
towards  the  temple  If  the  edge  is  inward,  the  direction  is 
moved  towards  the  nose. 

We  may  then  unite  prismatic  lenses  (with  their  edges  outward) 
to  the  proper  convex  lenses,  to  give  repose  to  the  muscles  of  con- 
vergence as  well  as  of  accommodation,  in  presbyopic  eyes.  The 
right  prisms,  as  well  as  convex  lenses,  may  be  selected  by  com- 
parative trial ;  although  oculists  have  precise  rules  for  their 
determination.  Glasses  in  which  this  combination  has  been 
made  are  called  orthoscopir.     (See  Fig.  143.) 

Convex  glasses  of  ^'^v  will  not  be,  generally,  too  high  in  power 
to  begin  with.  As  years  go  on,  these  will  come  to  be  insufficient, 
and  ^,  Jj,  ^,  j^  will  be  required.  Few,  even  in  late  old  age, 
will  need  a  higher  power  than  ^. 

Hiipermetropia  is  not  rare  even  in  young  persons.  Some  oph- 
thalmologists assert  that  it  is  more  common  at  all  ages  than 

'  Rapidly  increasing  presbyopia  is  one  of  the  signs  of  glaucoma.    See  p.  124. 


598  UNCLASSIFIED    DISEASES. 

emmetropia  or  ideally  perfect  visual  refraction.  During  child- 
hood and  youth,  slight  degrees  of  it  are  overcome  by  ciliary  mus- 
cular accommodation  ;  tobe  made  manifest  when  the  lens  grows 
less  elastic,  by  premature  presbyopia.  Considerable  degrees  of 
hypermetropia,  however,  cause  great  inconvenience,  and,  from 
strain  in  efforts  of  vision  (as  with  children  in  school)  serious 
asthenopia  may  be  produced. 

Fig. 143. 


Orthoscopic  Glasses. 

Correction  of  hypermetropia  is  obtained  by  the  use  of  convex 
glasses,  bringing  rays  of  light  to  a  focus  upon  the  retina  which, 
without  such  an  increase  of  their  convergence,  would  meet  be- 
hind the  abnormally  flat  or  shortened  eye. 

Authorities  advise  that  convex  glasses  for  hypermetropic  eyes 
(which  do  not,  unaided,  have  correct  vision  at 'any  distance) 
should  be  worn  all  the  time,  for  distant  as  well  as  near  vision. 
This  is  certainly  most  important  for  the  higher  degrees  of  hyper- 
metropia. When  presbyopia  comes  on,  with  loss  of  power  to 
accommodate  for  near  vision  (pushing  the  near  point  farther  from 
the  eye)  two  pairs  of  glasses  may  be  needed.  One  stronger  pair 
will  serve  for  reading  or  other  near  work  ;  the  accustomed 
weaker  glasses  for  ordinary  vision  at  a  distance.  Dr.  Benjamin 
Franklin  introduced  the  plan  of  putting  together  two  half-lenses 
in  the  same  frame ;  the  upper  half  weaker,  for  distant  sight ;  the 
lower  half,  stronger,  for  reading  or  near  work. 

Myopia  is  corrected  by  concave  glasses,  which  produce  diver- 
gence, or  diminish  convergence,  of  the  rays  of  light,  and  thus 
push  back  their  focus  so  as  to  make  it  fall  upon  the  retina,  giving 
clear  images.  This  makes  it  practicable  to  see  things  at  ordinary 
distances,  instead  of  their  being  brought  close  to  the  face.  It  is 
very  important  for  myopia  to  be  early  detected  and  cared  for  ; 
as,  more  than  hypermetropia,  it  tends  to  be  progressive,  and  to 
induce  disorder,  and  even  serious  organic  changes  in  the  eye. 
Some  authorities  declare  that  "every  near-sighted  eye  is  a 
diseased  eye." 

Cohn,  in  Germany,  and,  after  him,  Loring,  Derby,  Eisley,  and 
others  in  the  United  States,  have  shown  by  extended  investiga- 
tions that  errors  of  vision,  especially  myopia  and  astigmatism^ 


EYESIGHT.  599 

increase  remarkably  in  scViools,  ('oUeges,  and  universities.  In 
some  German  universities  the  near-sighted  students  constitute  (50 
per  cent,  of  tlie  wliole  number.  It  is  not  nearly  so  bad  in  any 
institutions  in  the  United  States ;  but  still  the  evil  exists. 
Hygienic  conditions  have  a  large  influence  in  this  matter,  espe- 
cially deficiencij  of  light  in  reading,  and  stooping  or  bending  over 
tlie  desk,  so  as  to  use  the  eyes  hahituallij  too  near  to  the  book  or 
lonrk.  Dr.  Kisley,  of  Philadelphia,  in  a  recent  report'  of  elabo- 
rate observations  made  in  the  public  schools  of  different  grades, 
shows  that,  under  the  best  possible  conditions,  healthy,  normal 
eyes  may  go  through  a  prolonged  course  of  study  Avithout  disad- 
vantage. "But,  he  adds,  "given  an  eye  with  an  anomaly  of 
refraction,  especially  astigmatism,  the  probabilities  are,  other 
things  being  equal,  that  the  educational  process  will  be  fraught 
with  pain  and  danger  to  the  eye."  Hence  follows  the  propriety 
of  the  careful  examination  of  all  eyes  that  give  trouble  early  in 
life  ;  so  as,  by  proper  treatment,  to  protect  them  from  injury 
and  increasing  disorder. 

Near-sighted  persons  can  get  along  tolerably  (unless  their 
myopia  is  extreme)  without  glasses,  in  walking  about,  requiring 
them  most  when  they  read  or  write,  etc.  v  But,  to  see  the  world 
aright,  for  enjoyment  and  mental  development,  such  persons 
ought  to  wear  glasses  generally  ;  the  stronger  pair  for  distant 
objects,  the  weaker  ones  for  reading  or  fine  work. 

Age  changes  the  myopic  eye  by  lessening  its  power  of  accom- 
modation within  the  short  range  between  its  near  and  far  point 
of  vision.  Although  nothing  is  then  carried  so  near  for  sight, 
and  thus  the  "short-sightedness"  is  less,  the  far  point  is  not 
often  pushed  farther  off.  Some  persons,  however,  having  slight 
myopia,  find  it  to  be  so  neutralized  by  the  flattening  of  the  lens 
witli  age,  as  to  be  able  to  do  without  glasses  at  the  time  of  life 
when  others  need  to  wear  them.  Again,  with  moderate  myopia, 
tlie  presbyopic  change  may  put  back  the  far  point  to  sucli  a  dis- 
tance that  convex  glasses  are  needed  for  reading,  while  concave 
ones  are  required  in  order  to  see  clearly  at  a  distance.  A  clergy- 
man, for  example,  may  be  unable  to  see  his  congregation  before 
him,  and  yet,  without  "  old-sight"  glasses,  he  cannot  read  his 
sermon  at  the  ordinary  distance.  This  state  of  things  may  be 
remedied  on  Franklin's  plan — by  having  the  upper  half  of  each 
glass  coucaue,  for  distant  sight,  and  the  lower  half  convex  for  near 
use. 

Astigmatism  is  to  be  corrected  by  cylindrical  lenses.  If  the 
corneal  curvature  were  made  sharper  from  side  to  side  than  from 
above  downwards,  the  eye  would  thereupon  become  myopic  for 
vertical  lines,  without  change  in  regard  to  horizontal  lines.  Or, 
if  the  upper  and  lower  curves  of  the  cornea  (or  crystalline  lens) 
were  made  sharper,  myopia  in  the  horizontal  meridian  only 
would  result. 

Briefly,  then,  it  may  be  said  that  "when  astigmatism  produces 
myopia  for  lines  of  a  given  direction,  we  may  correct  it  by  a  con- 
cave cylinder  with  its  axis  in  the  same  direction.     "When  it  pro- 

1  Phila.  Med.  Times,  July  30, 1881,  p.  673. 


600 


UNCLASSIFIED    DISEASES. 


duces  hypermetropia  for  lines  in  a  given  direction,  we  may  cor' 
rect  it  by  a  convex  cylinder  with  its  axis  in  the  same  direction.'" 
When,  along  with  astigmatism,  there  is  myopia,  hypermetropia, 
or  presbyopia,  the  appropriate  correction  must  be  made  for  both 

errors  ;  one  side  of  each  lens 
Fig.  144.  being  made  cylindrical  for  the 

astigmatism,  and  the  other 
side  spherical,  i.  e.,  a  section 
of  a  sphere,  convex  or  con- 
cave, according  to  the  kind 
of  ametropia  present. 

Attention  to  even  slight 
deficiencies  of  sight  ought 
never  to  be  neglected.  As 
has  been  well  said  by  an 
authority  already  quoted, 
'  *•  wherever  there  is  discomfort, 
there  is  a  possible  or  inohahle 
source  of  disease.''"' 

Color-blindness  has  at- 
tracted much  attention  of 
later  years.  Its  importance 
grows  especially  out  of  the 
danger  of  accidents  from  mistakes  mad^e  in  minding  signals  on 
railroads,  and  in  navigation.  Lives  are  said  to  have  been  lost 
from  such  blunders  on  the  part  of  signal-men,  switch-tenders, 
engineers,  pilots,  etc. 

'Inability  to  distinguish  red  from  green  is  the  most  marked  form 
of  this  defect,^  which  is  nearly  (though  not  quite)  always  con- 
genital. About  one  man  in  every  twenty-five  is  more  or  less  color- 
blind ;  the  proportion  amongst  women  is  very  much  less. 

Examination  to  determine  the  existence,  nature,  or  degree  of 
color-blindness,  must  be  made  with  great  care.  Merely  naming 
the  different  colors  will  not  suffice,  as  acquaintance  with  the 
terms  used  may  be  very  much  a  matter  of  education.^  There- 
fore Holmgren's  method  is  much  the  best :  of  placing  before  the 
person  under  examination  carefully  selected  colored  worsteds, 
which  he  is  required,  in  succession,  to  match,  from  a  large  num- 
ber of  skeins  of  different  colors,  placed  promiscuously  together.* 
While  aggravated  color-blindness  does  not  seem  capable  of  cor- 
rection by  any  treatment,  lesser  degrees  of  it  may  probably  be, 
at  least  in  early  life,  mitigated,  if  not  removed,  by  training  the 
eyes  to  recognition  of  different  colors  by  frequent  practice, 
(On  Disinfectants,  see  the  end  of  the  book.) 


1  Carter,  op.  cilat.,  p.  488. 

2  John  Dalton,  the  eminent  chemist,  was  subject  to  this;  whence  it  is  sometimes 
called  daltonism. 

3  Savages  discriminate  only  between  strong  colors.  Gladstone  has  shown  that  even 
the  Greeks  of  the  Homeric  period  had  a  verj'  limited  vocabulary  for  colors. 

*  W.  Wood  &  Co.,  New  York,  have  prepared  an  inexpensive  and  convenient  set  of 
"  Ophthalmic  Test-Types  and  Color-Bliuduess  Tests,"  with  lenses,  etc.,  and  Explana- 
tory Text. 


FORMULA. 


EvEKY  phj'-sician  should  acquire  such  knowledge  of  the  reme- 
dii's  he  employs  as  to  prescribe  and  combine  them  according  to 
tlie  indications  of  particular  cases  ;  not  by  the  routine  of  names 
of  diseases ;  and  still  less  by  fixed  receipts  or  formulae.  While 
this  is  obvious,  all  routine  being,  as  such,  bad  practice,  a  beginner 
may  yet  find  advantage,  and  a  practitioner  of  experience  may 
occasionally  save  time,  by  having  some  exmiplurs  of  prescriptions 
at  hand  for  reference.  A  selection  of  sucli  examples  is,  therefore, 
given.  Many  of  the  recipes  are  original,  and  all  are  carefully 
made  ;  the  number  being  very  much  less  extended  than  it  might 
easily  have  been,  in  accordance  with  the  principle  above  laid  down. 
Those  first  given  will,  for  convenience,  follow  mainly  the  order  of 
the  diseases  for  which  they  are  most  likely  to  be  required,  as  those 
diseases  are  treated  of  in  Part  II.,  of  this  book.  (See  a  later 
page,  for  metric  prescriptions. ) 

The  doses  in  these  prescriptions,  unless  otherwise  stated,  are 
intended  for  adults.  To  reduce  the  dose  of  any  drug  (except  nar- 
cotics, and,  perhaps,  mercurials)  according  to  the  age  of  a  child, 
the  rule  suffices  to  divide  the  dose  for  an  adult  in  proportion  to 
the  number  of  years  of  the  child's  age,  increased  by  12.  Thus, 
for  a  child  of  two  years,  the  dose  will  be  j^ths  (2  divided  by  2+12) 
or  ith  of  that  for  an  adult ;  for  a  child  of  three  years  (3  divided 
by  3-(- 12=15),  f^ths  or  ^th,  etc.  Opium  and  other  narcotics  act 
more  powerfully  in  proportion  upon  children  ;  so  that  their  dose 
should  be  reduced  in  a  greater  degree.  Calomel  and  other  mer- 
curials do  not  so  readily  alfect  the  glands,  at  least,  in  children  as 
in  adults. 

SimpUciti/  is  made  an  especial  aim  in  the  following  formulae ; 
considering  in  this  the  advantage  rather  of  the  tyro  than  of  the 
practitioner  of  experience. 

MEDICINES  EEFERRED   TO   IN  PART   II. 

1.  Solution  of  Tartar  Emetic, 

R. — Tartrate  of  Antimony  and  Potassium,  two  grains;  Water,  four 
flnidounces ;  dissolve.  Take  one  or  two  teaspoonfuls  every  two,  three, 
or  four  hours. 

lu  active  pneumonia,  pleurisi/,  severe  hronchitis,  pericarditis,  etc. 

2.  Quinine  Solution. 

B- — Sulphate   of    Quinine,   half   a   drachm;  Aromatic   Sulphuric 

Acid  ("Elixir  of  Vitriol),  a  fluidrachm  and  a  half;  Oil  of  Cloves,  four 

drops ;  Mucilage  of    Gum  Arabic,  a  fluidounce ;  Peppermint  Water, 

51  601 


602  FORMULA. 

enough  to  make  in  all  four  fluidounces ;  mix.  Take  a  teaspoonful  or 
two  every  three  or  four  hours,  in  asthenic  pneumonia,  low  fevers,  etc., 
as  a  supporting  remedy ;  larger  doses,  or  the  same  at  shorter  intervals, 
for  intermittent  fe'oer^  etc. 

3.  Ammonia  Mixture. 

R. — Carbonate  of  Ammonium,  one  drachm;  Mucilage  of  Gum 
Arabic,  four  Huidounces ;  Orange-flower  Water,  or  Peppermint  Water, 
two  fluidounces ;  mis.  Dose,  a  dessertspoonful,  or  tablespoonful,  every 
hour. 

Incases  of  general  prostration,  typhoid  pneumonia,  influenza  of  old 
people,  etc. 

4.  Nitrate  of  Potassium. 

R. — Nitrate  of  Potassium,  two  drachms;  Powder  of  Gum  Arabic, 
or  White  Sugar,  two  drachms ;  divide  into  twelve  papers.  Take  one 
every  two  or  three  hours. 

In  mild  pneumonia,  hronchitis,  etc. 

6.  Wine  of  Ipecacuanha. 
R . — Wine  of  Ipecacuanha,  half  a  fluidoimce.     Take  twenty  drops 
every  two  or  three  hours,  in  a  tablespoonful  of  water. 
In  tonsillitis,  erysipelas,  etc. 

6.  Calomel.,  Ipecacuanha,  and  Nitre. 

R. — Calomel,  and  Ipecacuanha  powder,  each  six  grains;  Nitrate 
of  Potassium,  half  a  drachm,  or  a  drachm ;  mix,  and  divide  into  twelve 
powders.     Take  one  powder  every  three  hours. 

In  pneumonia,  pleurisy,  etc. 

7.  Solution  of  Acetate  of  Ammonium. 
Dissolve  two  scruples  of  Carbonate  of  Ammonium  in  four  fluid- 
ounces  of  Water,  and  add  pure  Vinegar  slowly,  imtil  it  ceases  to  effer- 
vesce. This  will  substitute  the  "liquor  ammouii  acetatis"  or  Spiritus 
Mindercri.  Dose,  a  dessertspoonful,  or  a  tablespoonful,  with  as  much 
of  water,  every  two  or  three  hours;  in  anj  febrile  affection,  where 
purging  is  not  desirable,  as  a  diaphoretic. 

8.  Acetate  of  Potassium. 

R. — Acetate  of  Potassium,  five  drachms  and  a  half;  Sweet  Spirits 
of  Nitre,  two  fluidrachms;  Watei',  enough  to  make  eight  fluidounces; 
dissolve.     Take  a  tablespoonful  every  three  or  four  hours. 

In  feeble  cases  of  pneum.onia,  instead  of  tartar  emetic;  also  as  a 
diuretic,  in  pleuritic  effusion,  etc. 

9.  Calomel.,  Opium,  and  Tartar  Emetic. 
R. — Calomel,  six  grains;  Opium,  three  to  six  grains ;  Tartar  Emetic, 
a  grain  and  a  half;  mix,  and  divide  into  twelve  powders.     Take  one 
every  three  or  four  hours  in  water. 
In  acute  pleurisy . 

10.  Squills  and  Digitalis. 
R . — Powder  of  Squills,  half  a  drachm ;  Powder  of  Digitalis,  eight  to 
sixteen  grains ;  mix,  and  divide  into  sixteen  pills.  Take  one  thrice  daily. 
In pleui'itic  effusion. 


FORMUJ.iE,  608 

11.  Onnjjound  Spirit  of  Juniper. 
R. — Coniponiul  Spirit  of  Juniper,  two  iluidounces.     Take  one  or 
two  toaspoonfiils  thrice  duily,  in  a,  winegliissfiil  of  water. 

As  a  diuretic,  in  pleuritic  effusion,  etc.,  especially  infeehle  cases. 

12.  Juniper  Infusion  and  Cream  of  Tartar. 

R. — Bruised  Juniper  Berries,  one  ounce;  infuse  for  two  hours  in  a 
pint  of  Hot  W^ater ;  pour  off,  and  add  a  tablcspoonful  or  two  of  Bitar- 
trate  of  Potas.siuni.     Stir  and  drink  in  portions  through  the  day. 

In  dropsical  ejfusiua  of  any  hind. 

13.  Squills,  Nitre,  and  Digitalis. 

R . — Nitrate  of  Potassium,  two  drachms ;  Oxymel  of  Squills,  a  fluid- 
ounce;  Tincture  of  Digitalis,  half  a  tluidrachm  ;  Vinegar,  a  table- 
spoonful;  Sugar  and  Gum  Arabic,  each  two  drachms;  Water,  enough 
to  make  in  all  six  tluidounces ;  mix.  Take  a  tablespoonl'ul  every 
three  hours. 

In  acute  hroncldtis,  influenza,  etc. 

14.  Squills  and  Tartar  Emetic. 
R. — Tartar  Emetic,  one  grain;  Syrup  of  Squills,  four  ounces;  mix. 
Take  a  tablespoonful  every  three  or  four  hours. 
In  hronchitis,  with  dry  cough. 

15.  Squills  and  Paregoric. 

R. — Syrup  of  Squills,  three  fluidounces;  Paregoric  (Camphorated 
Tincture  of  Opium),  one  fluidounce;  mix.  Take  a  teaspoonful  three 
or  four  times  daily,  or  two  teaspoonfuls  at  night. 

In  bronchitis  or  influenza,  after  loosening  the  cough. 

16.  Muriate  of  Ammonia. 

R . — Chloride  of  Ammonium,  three  drachms;  Mucilage  of  Gum  Ara- 
bic, four  fluidounces ;  mix.     Take  a  tablespoonful  four  times  daily. 
In  chronic  bronchitis,  etc. 

17.  Copaiba  Mixture. 

R. — Balsam  of  Copaiba,  three  fluidrachms;  Compound  Spirit  of 
Lavender,  two  fluidrachms;  White  Sugar  and  Gum  Arabic,  each 
two  drachms;  Water,  enough  to  make  six  fluidounces;  mix.  Take  a 
tablespoonful  thrice  daily. 

In  chronic  bronchitis. 

18.  Lobelia  and  Ipecacuanha. 

R.— Tincture  of  Lobelia  and  Wine  of  Ipecacuanha,  each  half  a 
fluiduuace;  mix.  Take  one-half  teaspoonful  every  half  hour  until 
expectoration  or  nausea  occurs. 

In  asthma. 

19.  Ifusk  Mixture. 

R. — Musk,  two  scruples;  Syrup  of  Orange,  one  fluidounce;  Mucil- 
age of  Gum  Arabic,  three  fluidounces;  mix.  Take  a  tablespoonfid. 
every  two  or  three  hours. 

In  sjMsmodic  cough  of  any  hind,  or  other  s2Jasmodic  affections. 


604  FORMULA. 

20.  Hydrocyanic  Acid. 

R . — Dilute  Hydrocyanic  Acid,  sixteen  drops ;  Syrup  of  Wild 
Chei-ry,  and  Camphor  Water,  each  one  iiuidounce ;  mix.  Dose,  a  tea- 
spoonful  every  two  or  three  hours. 

In  violent,  trouilesome  cough. 

21.  Nitro-muriatic  Acid. 

R. — Nitro-muriatic  Acid,  half  a  fluidounce  (or  Nitric  Acid,  one 
fluidrachm  and  a  half;  Muriatic  Acid,  two  and  a  half  fluidraclims). 
Take  three  or  four  drops  twice  or  thrice  daily,  with  water,  in  a  glass. 

In  general  or  gastric  del>ility,  chronic  or  subacute  jaundice^  etc. 

22.  Bromide  of  Potassium. 

R . — Bromide  of  Potassium,  half  an  ounce ;  Peppermint  or  Cinna- 
mon Water,  or  Pure  Water,  six  fluidounces.  Dose,  from  a  dessert- 
spoonful to  a  tablespoonful. 

In  insomnia,  hysteria,  spermatorrhcea,  etc. 

23.  Citrate  of  Iron. 

R. — Citrate  of  Iron,  two  drachms;  Orange-flower  Water,  five  ounces 
and  a  half;  Simple  Syrup,  half  an  ounce.  Take  from  a  teaspoonful 
to  a  tablespoonful  thrice  daily,  before  or  after  meals. 

For  anaemic  children. 

24.  Ipecacuanha  and  Alum. 
R. — Powder  of  Ipecacuanha  and  Powder  of  Alum,  each  half  a  tea- 
spoonful  ;  mis  with  water.   Eepeat  in  ten  minutes  if  it  does  not  vomit. 
In  threatening  croup. 

25.  Calomel  and  Nitrate  of  Potassium. 

R. — Calomel,  six  to  twelve  grains;  Nitrate  of  Potassium,  one 
drachm ;  Sugar,  one  scruple ;  mix,  and  divide  into  twelve  powders. 
Take  one  every  three  hours. 

In  inflammatory  croup. 

26.  Nitrate  of  Silver  Solution. 

R. — Nitrate  of  Silver,  five  to  ten  grains;  Eose-water,  or  Distilled 
Water,  half  a  fluidounce ;  dissolve.  Apply  with  a  camel's-hair  pencil 
to  the  throat,  in  memiranotis  croup,  or  scarlet/ever. 

27.  Tincture  of  Aconite  Boot. 

R. — Saturated  Tincture  of  Aconite  Root,  one  teaspoonful.  To  be 
rubbed  gently  into  the  sMnfor  neuralgia. 

28.  Cliloroform  Liniment. 

R. — Chloroform,  three  fluidounces;  Olive  Oil,  four  fluidounces; 
mix. 

Pure  chloroform,  prevented  from  evaporating  by  oiled  silk  or  a 
watch-glasie,  acts  as  a  strong  rubefacient ;  burning  like  mustard. 

29,  Ointment  of  Veratria. 

R. — Veratria,  ten  to  twenty  grains;  Pure  Lard,  one  ounce;  mix. 
In  severe  neuralgia;  applied  to  the  part. 


FORMULA.  605 

30.  Cod-liver  Oil. 

g.. — Cod-liver  Oil,  Syriip  of  Ginger,  .ind  Mucilage  of  Gum  Arabic, 
each  two  riuidoimces;  Oil  of  Cloves,  six  drops;  mix.  Take  a  table- 
spoonful  tbree  or  four  times  daily. 

In  wanting  diseases. 

31.  Cod-liver  Oil  and  Glycerin. 
R. — Cod-liver  Oil  and  Glycerin,  each  tvvoHuidounces;  Gum  Arabic, 
two  drachms;    Oil  of   Bitter  Almonds,  two   drops;    Oil  of   Cloves, 
twelve  drops.     Take  a  tablespoonful  thrice  daily. 

32.  Cod-liver  Oil  and  Glycerin.,  Iron.,  and  Quinine. 
R. — Take  of  Citrate  of  Anuiionium,  Iron,   and  Quinine,  each  ten 
grains;  Cod-liver  Oil  and  Glycerin,  each  two  liuidounces;  mix.     Dose, 
a  tablespoonful. 

33.  Iodide  of  Iron. 
R. — Syrup  of  the  Iodide  of  Iron,  half  a  fluidounce.     Take  twelve 
to  twenty  drops,  in  water,  thrice  daily. 
Ill  ancemia,  scrofula,  etc. 

34.  Tincture  of  ISfiix  Vomica. 
R. — Tincture  of  Nux  Vomica,  half  a  fluidounce.     Take  from  ten 
to  thirty  drops,  thrice  daily. 

In  nervous  debility,  aggravated  dyspepsia,  etc. 

35.  Wild  Cherry  and  Lactucarium. 

R. — Syrup  of  Wild  Cherry,  and  Syrup  of  Lactucarium,  each  two 
fluidounces;  mix.  Take  a  dessertspoonful  or  two,  at  night,  or  one  or 
two  teaspoonfuls  in  the  daytime. 

In  J'requent  and  troublesome  cough;  as  iii  jjhtMsis. 

36.  Hoffmann'' s  Anodyne,  Squills,  and  Morphia. 

R. — Syrup  of  Squills,  a  fluidounce  and  a  half;  Hofl'mann's  Anodyne 
(Compound  Spirit  of  Ether),  and  Solution  of  Mori)hia  (one  grain  in 
the  ounce),  each  a  fluidounce;  Camphor  Water,  and  Mucilage  of  Gum 
Arabic,  of  each  a  fluidounce  and  a  quarter;  mix.  Dose,  from  a  tea- 
spoonful  to  a  tablespoonful. 

In  troublesome  coughs. 

37.  Carbonate  of  Potassium  and  Nitre. 
R. — Carbonate  of  Potassium,  and  Nitrate  of  Potassium,  each  two 
drarhms  and  a  half;  Water,   eight   fluidounces;    dissolve.      Take  a 
tablespo(mful  thrice  daily. 
In  gouty  attacks. 

38.  Digitalis,  Squills,  etc. 
R. — Citrate  of  Potassium,  two  hundred  grains ;  Tincture  of  Squills, 
two  fluidrachms;  Wine  of  Colchicum  Root,  one  fluidrachm ;  Liquor 
of  Acetate  of  Ammonium,  two  fluidrachms;  Infusion  of  Digitalis,  two 
fluidounces;  Pe])permint  Water,  enough  to  make  eight  fluidounces; 
mix.     Take  half  a  wineglassful  thrice  daily. 
In  dropsical  effusions. 
51* 


606  FORMULA. 

39.  Cream  of  Tartar  and  Dandelion. 

R. — Bitartrate  of  Potassium,  an  ounce;  Extract  of  Taraxacum,  half 
a  drachm ;  Decoction  of  Taraxacum,  eight  tiuidounces ;  mix.  Take 
half  a  wineglassful  two  or  three  times  a  day. 

In  dropsy  or  jaundice. 

40.  Cider  Mixture. 

B. — Bruised  Juniper  Berries,  Mustard  Seed,  and  Ginger,  each  half 
an  ounce ;  Bruised  Horseradish  and  Parsley  Root,  each  an  ounce ; 
sound  old  Cider,  a  quart;  infuse.     Dose,  a  wineglassful  thrice  daily. 

In  dropsy. 

41.  Acetate  of  Lead  Pills. 

R. — Acetate  of  Lead,  half  a  drachm;  Opium,  five  grains;  Conserve 
of  Roses,  or  Crumb  of  Bread,  a  snfiicient  quantity ;  mix,  and  divide 
into  twenty  pills.     Take  one  thrice  daily,  watching  the  effect. 

In  hy2Jertrop)hy  of  the  heart. 

42.  Digitalis. 

R. — Powder  of  Digitalis,  twelve  grains;  divide  into  twelve  pills. 
Take  one  thrice  daily. 

In  cases  of  over-ra2nd  action  of  the  heart. 

43.  Digitalis. 

R . — Tincture  of  Digitalis,  half  a  fluidounce.     Take  ten  drops  thrice 
daily,  in  water. 
As  above, 

44.  Yeratrum  Viride. 

R. — Norwood's  Tincture  of  Veratrum  Viride,  half  a  fluidounce. 
Take  from  two  to  five  drops  every  three  or  four  hours.  If  nausea  or 
prostration  follow,  withdraw  or  diminish  the  dose. 

In  hypertrophy  of  the  heart,  and  inflammatory  fever. 

45.  Colchicum  and  Magnesia. 

R. — Wine  of  Colchicum  Root,one  fluidrachm;  Husband's  Magne- 
sia, one  drachm ;  Peppermint  Water,  four  fluidounces ;  mix.  Take  a 
tablespoonful  thrice  daily. 

In  gout  and  gouty  rheumatism. 

46.  Colchicum  and  Alkalies. 

R. — Wine  of  Colchicum  Root,  one  fluidrachm;  Bicarbonate  of 
Potassium,  and  Rochelle  Salts,  each  two  drachms  and  a  half;  Pep- 
permint Water,  four  fluidounces ;  mix.  Take  a  tablespoonful  thrice 
daily. 

In  gout  and  gouty  rheumatism. 

47.  Hoffmann^s  Anodyne.,  Ammonia.,  and  Soda. 

R. — Bicarbonate  of  Sodium,  four  scruples;  Aromatic  Spirit  of 
Ammonia,  one  fluidrachm;  Compound  Spirit  of  Ether,  one  fluidounce; 
Compound  Tincture  of  Cardamom,  three  fluidrachms ;  Camphor 
Water,  and  Mucilage  of  Gum  Arabic,  each  a  fluidounce  and  a  quarter ; 
mix.     Take  a  dessertspoonful  or  tablespoonful  at  once. 

In  angina  pectoris,  or  gout  of  the  stomach  or  heart. 


FORMULA.  607 

48.  Warner^ s  Cordial  and  Laudanum. 

R. — Tincture  of  Rhubarb  and  Senna,  a  tiuidounce-  and  a  half; 
Syrup  of  (iinfj;er,  tliree  tluidrachnis;  Laudanum,  one  fluidracliin  ;  mix. 
Take  a  teaspoontul  at  once,  in-liot  water. 

Jii  angiiKi  pectoris^  or  spasmodic  gout. 

49.  Chloroform-.!  IIoffmann''s  Anodgne,  etc. 

R. — Chloroform,  and  Aromatic  Spirit  of  Ammonia,  each  two 
fluidrachms;  llotfmann's  Anodyne,  and  Paregoric,  each  half  an 
ounce;  Mucilajre  of  Gum  Arabic,  half  an  ounce;  mix.  Take  a  tea- 
spoonful  at  once. 

In  angina  j)ectoris,  retrocedent  gout,  etc. 

50.  Glycerin  and  Rose  Water. 
R. — Glycerin,  one  part;  Eose  Water,  five  parts;  mix.     Use  as  a 
lotion  for  the  skin,  or  a  mouth-wash. 

51.  Prepared  Chalk  and  Gum  Arabic. 
R. — Equal  parts  of  finely  powdered  Prepared  Chalk,  and  Powder 
of  Gum  Arabic;  mix. 

Ajyply  to  ulcerated  places  in  the  mouth. 

52.  Borax,  Myrrh,  etc. 
R . — Borate  of  Sodium,  two  drachms ;  Powdered  Myrrh,  one  drachm ; 
Water,  six  fiuidonnces;  mix. 
Use  as  mouth-wash,  or  gargle. 

53.  Sulphate  of  Zinc  and  Rose  Water. 
R. — Snlpbate  of  Zinc,  from  two  to  ten  or  twenty  grains;  Rose 
Water,  a  fliiidounce;  dissolve. 

Use  as  a  mouth-wash,  with  care,  in  severe  eases. 

54.  Chlorate  of  Potassium. 
R. — Chlorate  of  Potassium,  half  an  ounce;  Water,  six  fluidounces; 
dissolve.     Take  a  tablespoonful  every  three  or  four  hours. 
In  ulceration  of  the  mouth  or  throaty  diphtheria,  etc, 

55.  Muriatic  Acid  and  Honey. 

R. — One  part  of  Hydrochloric  Acid,  and  two  parts  of  Honey;  mix. 
To  be  applied  to  the  throat  in  diphtheria,  with  a  soft  sponge,  firmly 
fastened  to  a  (probang)  piece  of  whalebone. 

In  diphtheria. 

56.  Tincture  of  Chloride  of  Iron. 

R. — Tincture  of  Chloride  of  Iron,  half  a  fluidounce.  Take  from 
ten  to  thirty  drops  thi-ice  daily,  in  water. 

In  ancemia,  diphtheria,  menorrhagia,  leucorrhcBa,  asthenic  ery- 
sipelas, etc. 

57.  Clilorinated  Soda  and  Glycerin. 
R. — Labarraque's  Solution  of  Chlorinated  Soda,  one  fluidrachm; 
Bower's  Glycerin,  and  Water,  each  two  fluidounces ;  mix. 
Use  as  mouth-wash,  in  gangrcena  oris. 


608  FORMULA. 

58.  Creasote  and  Glycerin. 
R. — Creasote,  two  or  three  drops;  Bower's  or  Price's  Glycerin, 
and  Water,  each  half  a  iiuidounce ;  mix. 

Use  as  mouth-wash,  in  cuncrum  or  gangrcena  oris,  or  severe  aphthm 
or  thrush. 

59.  Alum,  Brandy,  and  Water. 
R . — Ahim,  one  drachm ;  dissolve  in  six  fluidounces  of  Water ;  add 
two  fluidounces  of  Brandy. 

To  wash  the  mouth  in  salivation. 

60.  Tannic  Acid  Solution. 
R. — Tannin,  ten  to  thirty  grains;  Water,  a  fluidounce;  dissolve. 
To  he  applied  with  a  hair  pencil,  to  enlarged  tonsils,  etc. 

61.  Iodide  of  Potassium. 

R. — Iodide  of  Potassium,  one  to  two  drachms;  Cinnamon  or  Pep- 
permint Water,  six  fluidounces ;  dissolve.  Take  a  tablespoonful  thrice 
daily. 

As  alterative  in  syphilitic  rheumatism,  and  in  many  other  affec- 
tions. 

62.  Nitrate  of  Silver  Pills. 

R. — Nitrate  of  Silver,  five  grains;  Opium,  two  grains  and  a  half; 
mix,  and  divide  into  tv/enty  pills.     Take  one  thrice  daily. 
In  chronic  gastritis. 

63.  Subyiitrate  of  Bismuth. 

R. — Subnitrate  of  Bismuth,  one  to  three  drachms;  divide  into  twelve 
powders.     Take  one  three  or  four  times  daily,  in  water. 
In  gastric  or  intestinal  irritation. 

64.  Lime -Water  and  Milk. 

Mix  together  equal  parts  of  clear  Lime-water  and  good  Milk.  Take 
a  dessertspoonful  or  tablespoonful  of  the  mixture  at  once. 

To  check  vomiting,  or  give  nourishment  when  the  stomach  is  irri- 
table. 

65.  Effervescing  Draught. 

Dissolve  two  drachms  and  a  half  of  Bicarbonate  of  Potassium  in  four 
fluidounces  of  Water.  Pour  out,  for  administration,  a  tablespoonful 
of  this  solution,  and  add  to  it  a  tablespoonful  of  water.  Then  add  a 
tablespoonful  of  fresh  Lemon-juice ;  or  of  a  solution  containing  two 
drachms  of  Citric  Acid  in  four  fluidounces  of  Water. 

In  fever  with  irritability  of  stomach  ;  also,  in  sea-sickness. 

66.  Cardamom  and  Potassa  Mixture. 

R. — ^Bicarbonate  of  Potassium,  one  drachm;  Compound  Tincture 
of  Cardamom,  a  fluidounce ;  Syrup  of  Ginger,  two  fluidrachms;  Orange- 
flower  Water,  enough  to  make  four  fluidounces ;  mix.  Take  a  dessert- 
spoonful at  once. 

To  relieve  nausea  and  vomiting. 


FORMULAE.  609 

67.  Ammonia,  Soda,  and  Morphia. 

R. — Bicarbonate  of  Sodium,  four  scrni)les;  Aromatic  Spirit  of 
Ammonia,  one  Huidraclim;  Solution  of  Morphia,  two  rtuidraclims; 
Cinnamon  Water,  encnigli  to  make  four  tluidouuces.  Take  one  or  two 
teaspoonfuls  at  once. 

Ihr  vomiting. 

68.  Creasote,  Soda,  and  Morphia. 

R. — Creasote,  eight  droi)s;  Bicarbonate  of  Sodium,  one  drachm; 
Solution  of  ^forpbia,  a  tluidrachm  and  a  half;  Peppermint  Water, 
enough  to  make  four  tiuidouuces ;  mix.  Take  one  or  two  teaspoonfuls 
at  once. 

For  vomitinrj. 

69.  Calomel  Powders. 

R. — Calomel,  two  grains;  divide  into  eight  powders.  Take  one 
every  two  hours. 

For  vomiting,  etc, 

70.  S%iice  Poultice. 

R . — Powdered  Cloves,  Ginger,  and  Cinnamon,  each  one  or  two  tea- 
spoonfuls ;  Wheat  Flour,  a  tablespoonful ;  Brandy,  or  Whisky,  enough 
to  make  a  mass  moist  enough  to  spread  upon  thin,  soft  liannel. 
Double  the  flannel  over  it,  and  apply  it  to  the  abdomen. 

In  obstinate  vomiting,  etc. 

71.  Nux  Vomica,  Iron,  and  Quinine. 

R. — Pill  of  Carbonate  of  Iron  (Vallet's  Mass),  two  scruples  (or 
Quevenne's  Metallic  Iron  per  hydrogen,  one  scruple);  Sulphate  of 
Quinia,  one  scruple;  Alcoholic  Extract  of  Nux  Vomica,  five  grains; 
mix,  and  divide  into  twenty  pills.     Take  one,  thrice  daily. 

In  prolonged  atonic  dysj)epsia,  general  debility,  or  ganglionic  cachexia. 

72.  Tincture  of  Gentian  and  Rhuharh. 
R. — Compound  Tincture  of  Gentian,  and  Tincture  of  Ehubarb,  each 
two  fluidounces;  mix.     Take  two  teaspoonfuls  before  each  meal. 
In  dyspepsia. 

73.  Gentian  and  Bhid)arh  Pills. 
R. — Extract  of  Gentian,  and  Powder  of  Ehnbarb  Root,  each  half 
a  drachm ;  mix,  and  divide  into  twenty  pills.     Take  one  or  two  thrice 
daily. 

In  dyspepsia,  flahdence,  or  tendency  to  colic. 

74.  Gentian,  Rhuharh,  and  Blue  Mass. 

R. — Extract  of  Gentian,  and  Powder  of  Rhubarb,  each  half  a 
drachm  ;  Blue  Mass,  four  grains;  .Oil  of  Cloves,  four  drops;  mix,  and 
divide  into  twenty  pills.  Take  one  three  or  four  times  daily  for  a  few 
days. 

To  prevent  recurring  bilious  colic  or  sick  headache. 

75.  Rhuharh  Pills. 
R. — Rhubarb  Root,  and  Castile  Soap,  each  half  a  drachm;  Oil  of 
Anise,  four  drops ;  mix,  and  divide  into  twenty  pills.     Take  one  or 
two  as  recjuired. 

For  slight  constipation. 

20 


610  FORMULJE. 

76.  Rhuharh  and  Colocynth. 

R, — Rhubarb,  Castile  Soap,  and  Compound  Extract  of  Colocyntb, 
each  half  a  drachm;  mix,  and  divide  into  twenty  pills.  Take  one  or 
two  as  required. 

For  constipation. 

77.  Bhubarb  and  Aloes,  etc. 

R. — Rhubarb,  two  scruples;  Aloes,  one  scruple;  Extract  of  E"ux 
Vomica,  four  grains ;  mix,  and  divide  into  twenty  pills.  Take  one  as 
required. 

For  obstinate  constipation. 

78.  Carminative  Mixture. 

R. — ^Bicarbonate  of  Sodium,  one  drachm;  Compound  Tincture  of 
Cardamom,  one  fluidounce ;  Spirit  of  Camphor,  one  fluidrachm  (or. 
Paregoric,  half  a  fluidounce) ;  Spiced  Syrup  of  Rhubarb,  half  a  fluid- 
ounce;  Peppermint  Water,  enough  to  make  four  fluidounces.  Take  a 
teaspoonful  at  once. 

79.  Oil  of  Cajuput. 

R . — Oil  of  Cajuput,  half  a  fluidrachm ;  Compound  Spirit  of  Lav- 
ender, half  a  fluidounce;  Syrup  of  Ginger,  twQ  fluidrachms;  Mucilage 
of  Gum  Arabic,  enough  to  make  two  fluidounces.  Take  a  dessert- 
spoonful at  once. 

For  flatule?it  pain  in  the  bowels  ;  also,  in  chronic  rheumatism  or  gout. 

80.  Ammonio-ferric  Alum. 
R. — Ammonio-ferric  Alum,  two  scruples;  Cinnamon  "Water,  four 
fluidounces ;  dissolve.    Take  a  tablespoonf  ul  every  two  or  three  hours. 
An  excellent  tonic  astringent. 

81.  Creasote  Pills. 

R . — Creasote,  twenty  drops ;  Conserve  of  Roses  for  Extract  of  Gen- 
tian), one  drachm  ;  mix,  and  divide  into  twenty  pills.  Take  one  every 
two,  three,  or  four  hours. 

As  astringent,  in  hcematemesis,  ulcer  of  stomach,  etc. 

82.  Podophyllum,  etc. 

R . — Resin  of  Podophyllum,  two  grains ;  Fluid  Extract  of  Rhubarb, 
and  Fluid  Extract  of  Senna,  each  a  fluidounce ;  Oil  of  Cloves,  four 
drops ;  Syrup  of  Ginger,  half  a  fluidounce ;  Mucilage  of  Gum  Arabic, 
enough  to  make  four  fluidounces.     Dose  for  an  adult,  a  tablespoonf  ul. 

For  constipation. 

83.  Suppository  of  Soap. 

Cut  a  piece  of  good  Yellow  Soap  to  the  shape,  and  rather  less  than 
the  size,  of  the  last  joint  of  the  little  finger.  Dip  it  in  Castor  Oil, 
Olive  Oil,  or  Lard,  and  introduce  it  within  the  rectum. 

To  act  upon  the  bowels,  instead  of  an  enema. 

84.  Nux  Vomica,  Colocynth,  and  Soap. 

R. — Compound  Extract  of  Colocynth  and  White  Soap,  each  half  a 
drachm;  Extract  of  Nux  Vomica,  five  grains;  mix,  and  divide  into 
twenty  pills.     Take  one  niglit  and  morning. 

For  torpor  of  the  bowels. 


FORMULiE.  611 

85.  Aloes,  Bhuharh,  and  Belladonna. 

R, — Rlnib.irb  and  Aloes,  each  lialf  a  drachm;  Extract  of  Bella- 
donna, three  grains;  Oil  of  Cloves,  three  drops;  mix,  and  divide  into 
twenty  pills.     Take  one  twice  daily. 

Fo7-  habitual  constipaiion. 

80.  Calomel  and  Opium  Pills, 
R. — Calomel  and  Opium,  each  six  grains;  mix,  and  divide  into 
twelve  pills.     Take  one  every  two,  three,  or  four  hours. 
In  peritonitis,  bilious  colic,  etc. 

87.  Bills  of  Opium  and  Ipecacuanha. 
R . — Powder  of  Opinin  and  Powder  of  Ipecacuanha,  each  six  grains ; 
mix,  and  divide  into  twelve  pills.     Take  one  every  three  hours. 
In  typhlitis. 

88.  Cerate  of  Carhonate  of  Lead. 
R . — Carbonate  of  Lead,  two  drachms ;  Simple  Cerate,  one  ounce ; 
mix. 

For  external  use  in  chronic  ophthalmia,  periostitis,  hemorrhoids,  etc. 

89.  Aromatics.1  etc.,  for  Colic. 
R. — Aromatic  Spirit  of  Ammonia  and  Spirit  of  Camphor,  each  a 
flnidrachm ;  Tincture  of   Ginger,   two  fiuidrachms;    Bicarbonate  of 
Sodium,  four   scruples;    Peppermint  Water,   enough   to   make   four 
tluidounces.     Dose,  a  tablespoonful, 

90.  Carminative  Anodyne. 

R. — Spiced  Syrup  of  Rhubarb,  Compound  Tincture  of  Cardamom, 
Paregoric,  and  Cinnamon  Water,  each  a  fluidounce ;  mix.  Dose,  from 
a  dessertspoonful  to  a  tablespoonful. 

For  crapulent  colic. 

91.  Chloroform  Mixture. 

R. — Chloroform,  a  fluidounce;  Camphor  Water,  Peppermint  Water, 
and  Mucilage  of  Gum  Arabic,  each  a  fluidounce ;  mix.  Dose,  from  a 
teaspoouful  to  a  dessertspoonful,  repeated  cautiously. 

For  colic,  etc. 

92.  Chloroform  Paregoric. — No.  1. 

R. — Chloroform,  Laudanum,  Spirit  of  Camphor,  and  Aromatic  Spirit 
of  Ammonia,  each  a  tluidrachm  and  a  half;  Creasote,  three  drops; 
Oil  of  Cinnamon,  eight  drops;  Alcohol,  two  fluidrachms;  mix.  Dose, 
fn)m  ten  drops  to  half  a  teaspoonful,  in  water. 

//*  cholera. 

93.  Chloroform  Paregoric. — No.  2. 

R. — Chloroform,  two  fluidrachms;  Spirit  of  Camphor,  a  tluidrachm 
and  a  half;  Laudanum,  a  tluidrachm;  Oil  of  Cinnamon,  five  drops; 
Alcohol,  three  and  a  half  tluidrachms ;  mix.  Dose,  ten  drops  to  half  a 
teaspoouful,  in  water. 

94.  Carminative  for  Infants. 
R. — Bicarbonate  of    Sodium,  half  a  draclim ;   Aromatic  Spirit  of 
Ammonia,  half  a  Huidrachm  ;  Solution  of  Morphia,  half  a  flnidrachm  ; 


612  FORMULAE. 

Syrup  of  Ginger,  half  a  fluidounce;  Camphor  Water,  enough  to 
make  two  fluidounces;  mix.  Dose,  a  teaspoonful,  repeated  if  nec- 
essary. 

In  colic. 

95.  Podo2)hyUu'm^  BMibarh,  etc. 

R. — Resin  of  Podophylhim,  one  grain;  Simple  Syrup  of  Rhubarb, 
a  fluidounce ;  Oil  of  Fennel,  one  drop ;  mix.  Dose,  ten  drops  to  a 
teaspoonful. 

For  constipation  in  infants. 

96.  Castor  Oil  and  Spiced  Syrup  of  Bhuharh. 
Mix  one  tablespoonful  of  Castor  Oil  thoroughly  with  two  table- 
spoonfuls  of  Spiced  Syrup  of  Rhubarb ;  administer  immediately  after 
mixture.     This  is  the  least  disagreeable  way  of  taking  castor  oil. 

97.  Castor  Oil  and  Laudanum. 
To  the  above   prescription,  add  ten,  twenty,  or  thirty  drops  of 
Laudanum. 

Useful  in  incipient  acute  dysentery. 

98.  Assafoetida  Mixture. 

Rub  one  drachm  of  Assafoetida  gradually  with  four  ounces  of 
Water,  until  thoroughly  mixed.  Then  add  two  fluidounces  of  Syrup 
of  Ginger. 

Dose,  for  a  child,  a  teaspoonful. 

99.  Magnesia  and  Ammonia  Mixture. 

R. — Best  Magnesia  (Husband's  or  Henry's),  a  drachm;  Aromatic 
Spirit  of  Ammonia,  a  fluidrachm  ;  Peppermint  Water,  four  fluidounces ; 
mix.  To  be  shaken  before  administration.  Take  a  teaspoonful  every 
half  hour. 

In  common  summer  cholera  morbus. 

Half  a  fluidounce  of  Paregoric  may  be  added  to  the  above,  if  there 
is  much  purging. 

100.  Chloroform  and  Gamplior. 

R. — Chloroform,  half  a  troyounce;  Camphor,  one  drachm;  the 
yolk  of  one  &§g\  Water,  six  fluidounces.  Rub  the  yolk  in  a  mortar, 
first  by  itself,  then  with  the  Camphor,  previously  dissolved  in  the 
Chloroform,  and  lastly,  with  the  Water,  gradually  added.  This  is  the 
"Mixture  of  Chloroform "  of  the  United  States  Pharmacopoeia. 

Dose,  from  a  teaspoonful  to  a  tablespoonful. 

101.  Spiced  Rhiibarh  and  Magnesia. 

R. — Spiced  Syrup  of  Rhubarb,  half  a  fluidounce;  Magnesia  (Hus- 
band's), fifteen  grains ;  Cinnamon  Water  and  Camphor  Water,  each 
two  fluidrachms ;  mix.     Take  in  two  doses,  three  hours  apart. 

As  a  corrective  in  slight  diarrhoea. 

102.  Chalk  Mixture. 
R. — Prepared  Chalk,  two  drachms;  White  Sugar  and  Gum  Arabic, 
each  a  drachm  and  a  half ;  Tincture  of  Kino,  two  fluidrachms  and  a 


FOKMULiE.  613 

half;  Laudannm,  twenty  to  forty  drops ;  Peppermint  Water,  enough 
to  make  six  fluidounces;  mix.     Dose,  a  tablespoonful. 

In  diarrhoea. 

103.  Cv.mphoT  Mixture. 

R. — Compoiind  Spirits  of  Lavender,  a  flnidmmce;  Spirit  of  Cam- 
phor, a  fhiidrachm;  Laudanum,  half  a  fluidracLm ;  Sugar  and  Gum 
Arabic,  each  a  drachm  and  a  half;  Cinnamon  "Water,  enough  to  make 
six  fluidounces;  mix.    Dose,  a  tablcspoonful  onco  in  three  hours. 

In  diarrhtta. 

lOi.  Lead  and  Morphia  Mixture. 

R . — Acetate  of  Lead,  eight  to  sixteen  grains ;  Acetate  of  Morphia, 
one  grain ;  Gum  Arabic,  two  drachms ;  Cinnamon  Water,  enough  to 
make  eight  fluidounces;  mix.  Take  a  teaspoonful  every  three  or 
four  hours. 

In  obstinate  diarrhoea. 

105.  Catechu,  and  Paregoric. 
R. — Tincture  of  Catecliu  and  Paregoric,  each,  half  a  fluidounce; 
mix.     Take  a  teaspoonful  every  thi-ee  or  four  hours,  with  water. 
In  severe  diarrhoea. 

106.  Tannic  Acid  and  Opium. 

R . — Tannic  Acid,  thirty-six  grains ;  Powder  of  Opium,  three  to 
four  grains ;  mix,  and  divide  into  twelve  pills.  Take  one  every  three 
or  four  hours. 

To  check  diarrhoea. 

107.  Calomel.!  Soda.,  and  Ginger. 

R. — Calomel,  two  grains;  Bicarbonate  of  Sodium,  one  scruple; 
Powder  of  Ginger,  twelve  grains ;  mix,  and  divide  into  twelve  powders. 
Give  one  three  or  four  times  daily. 

In  incipient  cholera  infantum. 

108.  Mercury  with  Chalk  and  Cinnamon. 

R. — Mercmy  with  Chalk,  and  Powder  of  Cinnamon,  each  twelve 
grains ;  mix,  and  divide  into  twelve  powders.     Give  one  thrice  daily. 
In  the  early  stage  of  cholera  infantum. 

109.  Ammonia,  Bhubarb,  and  Paregoric. 

R. — Aromatic  Spirit  of  Ammonia,  twenty-five  drops;  Paregoric, 
half  a  fluidrachm  to  a  fluidrachm;  Spiced  Syrup  of  Rhubarb,  a  fluid- 
ounce;  Peppermint  Water,  enough  to  make  two  fluidounces  ;  mix. 
Give  a  teaspoonful  every  three  hours. 

In  cholera  infantum. 

110.  Rhatany  and  Paregoric. 
R. — Tincture  of  Krameria,  and  Paregoric,  each  a  fluidrachm ;  Sugar 
and   Gum  Arabic,  each   half  a   drachm ;  Cinnamon  Water,  diluted, 
enough  to  make  two  fluidounces ;  mix.     Give  a  teaspoonful  every  two, 
three,  or  four  hours. 

To  check  the  diarrhoea  of  cholera  infantum. 
52 


614  FORMULA. 

111.  Blue  Mass  and  Ipecacuanha. 
B . — Blue  Mass,  twelve  grains ;  Powder  of  Ipecacuanha,  six  to  twelve 
grains;  mix,  and  divide  into  twelve  pills.    Take  one  every  three  hours. 
In  incipient  dysentery. 

112.  Blue  Mass,  Ipecacuanha,  and' Camphor. 

g.. — Blue  Mass,  eight  grains;  Ipecacuanha,  six  grains;  Camphor, 
twelve  grains;  mix,  and  divide  into  twelve  pills.  Take  one  every 
three  hours. 

In  an  early  stage  of  dysentery. 

113.  Camphor.,  Ipecacuanha,  and  Opium. 

R.— Camphor,  eighteen  grains;  Ipecacuanha,  six  grains;  Opium, 
three  or  six  grains;  mix,  and  divide  into  twelve  pills.  Take  one  every 
three  or  four  hours. 

In  dysentery. 

114.  Acetate  of  Lead  and  Opium  Pills. 

R.— Acetate  of  Lead,  twelve  to  twenty -four  grains;  Opium,  three 
to  twelve  grains ;  mix,  and  divide  into  twelve  pills.  Take  one  every 
three  or  four  hours. 

In  dysentery. 

115.  Enema  of  Laudanum  and  Starch. 

Prepare  half  an  ounce  of  Starch,  thin  enough  to  be  drawn  into  a 
small  syringe ;  add  from  twenty  to  sixty  or  more  drops  of  Laudanum, 
according  to  the  case;  mix,  and  inject  into  the  bowel. 

In  severe  dysentery,  retention  of  urine,  very  painful  hemorrhoids,  etc. 

116.  Enema  of  Sulphate  of  Zinc  and  Laudanum, 
To  four  fluidounces  of  Flaxseed  Tea,    made  without  boiling,  add 

forty  drops  of  Laudanum,  and  from  four  to  ten  grains  of  Sulphate  of 

Zinc;  mix,  and  inject  into  the  rectum. 
In  obstinate  chronic  dysentery. 

117.  Quinine,  Ipecacuanha,  Camphor,  and  Opium. 

R. — Quinine,  two  scruples ;  Camphor,  two  scruples;  Ipecacuanha, 
ten  grains ;  Opium,  ten  grains ;  mix,  and  divide  into  twenty  powders 
(or  pills).     Take  one  every  three  or  four  hours. 

In  asthenic  malarious  dysentery. 

118.  Ointment  of  Galls  and  Opium, 
R. — Powder  of  Galls,  two  drachms  ;  Opium,  ten  grains;  Lard,  one 
ounce ;  mix.     Apply  as  ointment. 
Eor  piles. 

119.  Spermaceti  Ointment  and  Opium,. 
R. — Ointment  of  Spermaceti,  Ointment  of  Rose  Water  (Cold  Cream) 
or  Glyceramyl,  an  ounce ;  Opium,  ten  grains ;  mix.     To  be  used  as 
ointment. 
For  piles. 

120.  Belladonna  Ointment. 
R. — Extract  of  Belladonna,  a  drachm;  Spermaceti  Ointment,  an 
ounce;  mix.     Use  as  ointment. 
For  painful  piles. 


FORMULAE.  615 

121.  Tannic  AcAd  Wash. 
R. — Tannic  Acid,   twenty  to   thirty  grains ;  Water,   six  ounces; 
dissolve.     To  be  injected  (cooled  with  ice)  into  the  rectum  for  Heed- 
ing piles. 

122.  Soda  and  Sweet  Spirit  of  Nitre. 
R. — Bicarbonate  of  Sodium,  three  drachms;  Sweet  Spirit  of  Nitre, 
six  Huidrachms;  Peppermint  Watei",  enough  to  make  six  fluidounces ; 
dissolve.     Take  a  tablcspoonful  three  or  four  times  daily, 
//i  uric  acid  gravel. 

123.  Benzoic  Acid  and  Soda. 

R. — Bicarbonate  of  Sodium,  two  drachms;  Phosphate  of  Sodium, 
half  an  ounce;  Benzoic  Acid  and  Gum  Arabic,  each  two  drachms; 
Sweet  Spirit  of  Nitre,  lialf  a  fluidounce ;  Peppermint  Water,  enough 
to  make  six  fluidounces;  mix.  Take  from  a  teaspoonful  to  a  table- 
spoonful,  occasionally. 

Iti  gravel. 

124.  Ojnum  Suppositories. 

R. — Opium,  one  or  two  grains;  Cacao  (Cocoa)  Butter,  a  suflacient 
quantity ;  mix,  and  introduce  into  the  rectum. 

For  painful  hemorrhoids,  dysmenorrhoea,  irritation  of  the  bladder,  etc. 

125.  Belladonna  Suppositories. 
R. — Extract  of  Belladonna,  one  to  four   grains;  Cacao  Butter,  a 
sufficient  quantity;  mix,  and  introduce  into  the  bowel. 
Ihr  painful  hemorrhoids,  etc. 

126,  Benzoic  Acid. 
R . — Benzoic  Acid,  two  drachms ;  Cinnamon  Water,  six  fluidounces ; 
dissolve.     Take  a  tablcspoonful  thrice  daily. 

In  irritation  of  the  bladder,  incontinence  of  urine,  etc. 

127.  Groton  Oil. 

R. — Croton  Oil,  four  drops;  Crumb  of  Bread  or  Conserve  of  Roses, 
a  sufficient  quantity  to  make  four  pills;  mix,  and  divide.  Take  one 
every  four  hours,  until  they  operate. 

As  a  powerful  cathartic,  in  rare  cases. 

128.  Lead-ioater  for  the  Eyelids. 
To  a  fluidounce  of  pure  River,  Well,  or  Spring  Water,  add  one  drop 
of  Goulard's  Extract  of  Subacetate    of  Lead.     Apply  this  with   a 
earners- hair  pencil,  to  the  outside  of  the  lids,  frequently. 

129.  Alum  Eye-water. 
R.— Two  to  four  grains  of  Alum;  Water,  one  fluidounce ;  dissolve. 
Drop  into  the  eye  from  a  quill  or  a  hair  pencil,  once  or  twice  daily. 

130.  Collyrium  of  Nitrate  of  Silver. 
R. — Nitrate  of  Silver,  two   to   four   grains;  Distilled  Water,   one 
fluidounce;  dissolve.     Apply  to  the  inside  of   the  lids  with  a  hair 
pencil,  or  drop  between  the  lids. 


616  FORMULA. 

131.  Atropia  Solution  for  the  Eye. 
R . — Sulphate  of  Atropia,  two  to  four  grains  •  Water,  one  fluidounce ; 
dissolve.     Drop  into  the  eye  once  or  twice  daily. 
To  dilate  the  pupil;  as  in  iritis. 

132.  Lotion  for  the  Ear. 

B- — Glycerin  and  Warm  Water,  each  half  a  teaspoonful;  mix. 
Pour  into  the  ear  from  a  teaspoon  (in  preference  to  a  syringe)  twice 
daily. 

Ear  otalgia,  or  irritation  of  the  ear. 

138.  Olive  Oil  and  Laudanum. 
Mix  half  a  teaspoonful  of  warm  Olive  Oil  with  five  or  ten  drops  of 
Laudanum ;  pour  it  into  the  ear. 
For  earache. 

134.  Bromide  of  Ammonium,. 
R. — Bromide  of  Ammonium,  two  drachms ;  Water,  four  fluidounces ; 
Aromatic  Spirit  of  Ammonia,  one  fluidrachm ;  dissolve.     Take  a  des- 
sertspoonful thrice  daily. 
In  hysteria,  etc. 

135.  Besin  of  Jalap. 

B . — Eesin  of  Jalap,  one  scruple ;  divide  into  three  parts.    Give  one 
every  four  hours  till  they  operate. 
An  active  cathartic. 

136.  Podophyllum  Pills. 

R. — Eesin  of  Podophyllum,  two  grains;  Turkey  Ehuharb,  eight 
grains ;  Oil  of  Anise,  two  drops ;  divide  into  eight  pills.  Take  one 
or  two  at  once. 

Cathartic  and  cholagogue. 

137.  Strychnia. 

R. — Sulphate  of  Strychnia,  half  a  grain;  Conserve  of  Eoses,  six- 
teen grains;  mix,  and  divide  into  sixteen  pills.  Take  one  or  two 
thrice  daily. 

Cautiously,  in  many  cases  of  paralysis. 

138.  Stimulating  Liniment, 

R . — Oil  of  Turpentine,  Spirit  of  Camphor,  Water  of  Ammonia,  and 
Olive  Oil,  each  two  tablespoonfuls ;  mix  well  together,  for  external 
application. 

In  chronic  rheumatism,  bruises,  sprains,  etc. 

139.  Sassafras  Liniment. 
R . — Oil  of  Sassafras,  two  fluidrachms ;  Water  of  Ammonia,  a  table - 
spoonful;  Camphorated  Soap  Liniment,  three  fluidounces ;  mix. 
Eor  swelling  of  joints,  etc. 

140.  Cod-liver  Oil. 

R . — Cod-liver  Oil,  twenty-four  drachms ;  Alcohol,  twelve  drachms ; 
Essence  of  Peppermint,  twenty-four  grains;  mix.  Take  a  dessert- 
spoonful thrice  daily. 

In  phthisis,  chronic  rheumatism,  etc. 


FORMULi^.  617 

141.  Enema  of  Castor  Oil,  Soap,  and  Molasses. 

Mix  togetlier  a  tablespoonfiil  of  Oil,  and  the  same  of  Molasses,  with 
a  pint  of  warm  Water,  in  wliich  a  little  Castile  or  good  yellow  Soap 
has  been  dissolved.     Inject  into  the  rectum  with  a  syringe. 

To  empty  the  bowels  promptly. 

142.  Pliosphate  of  Iron. 

R. — Phosphate  of  Iron,  one  drachm;  divide  into  twelve  powders. 
Take  one  thrice  daily,  in  water. 
A  good  chalybeate  tonic. 

143.  Assufoetida  Pills. 

R. — Assafoetida,  one  drachm;  divide  into  twenty  pills.     Take  one 
every  two  or  three  hours. 
For  hysterical  nervousness. 

144.  Solution  of  Morphia  with  Valerian. 

R. — Solution  of  Siilphate  of  Morphia  (one  grain  to  the  fluidounce), 
and  Fluid  Extract  of  Valei-ian,  each  one  fluidounce;  mix.  Take  one 
or  two  teaspoonfuls,  as  required. 

In  delirium  tremens. 

145.  Pills  of  Opium,  Camphor,  and  Hyoscyamus. 

R. — Opium,  four  to  eight  grains;  Camphor,  twelve  grains ;  Extract 
of  Ilyoscyamus,  a  scruple ;  mix,  and  divide  into  twelve  piUs.  Take 
one  every  three  or  four  hours ;  or,  one  or  two  at  night. 

^  good  calmative- 

146.  Gallic  Acid. 

R. — Gallic  Acid,  two  drachms  and  a  half;  Syrup  of  Cinnamon,  four 
fluidounces ;  mix.  Take  a  dessertspoonful  every  two,  three,  or  four 
hours. 

As  astringent,  in  hemorrhages,  diabetes,  etc. 

147.  Oil  of  Turpentine  Mixture. 

R. — Oil  of  Turpentine,  two  to  four  fluidrachms;  Compound  Spirit 
of  Lavender,  half  a  fluidounce ;  Laudanum,  twenty  minims ;  Sugar 
and  Gum  Arabic,  each  two  drachms;  Water,  enough  to  make  six 
fluidounces;  mix.     Take  a  tablespoonful  at  once. 

In  hemorrhages,  typhoid  fever,  etc. 

148.  Glyceramyl. 

Mix  together  two  drachms  of  Starch,  and  two  fluidounces  of  Bower's 
or  Price's  Glycerin,  cold ;  heat  gradually  to  about  240°  Fahr.,  stirring 
all  the  time ;  then  let  it  cool. 

A  very  soothing  local  emollient, 

149.  Neutral  Mixture. 
R. — Citrate  of  Potassium,  two  drachms;  Lemon  Symp,  half  a  fluid- 
ounce;  Water,  three   and   a  half  fluidounces;  mix.     Dose,  a  table- 
spoonful  every  two  or  three  hours,  with  one  of  water,  in  fever.     The 
lemon  syrup  may  be  omitted  without  disadvantage, 
52* 


618  F  O  R  M  U  I.  JE . 

150.  Spiritus  Minder eri  with  Nitre. 

5t. — ^Liquor  of  Acetate  of  Ammonium,  three  fluidouuces  and  a  half; 
Sweet  Spirit  of  Nitre,  half  a  fluidounce ;  mis.  Take  a  tablespoonful 
every  two  or  three  hours,  with  a  little  water. 

In  typhoid  fever. 

151.  Jalap  and  Squills. 

R. — Kesin  of  Jalap,  half  a  drachm  to  a  drachm;  Squills,  twelve 
grains  to  a  scruple ;  mix,  and  divide  into  twelve  powders.  Take  one 
at  once. 

As  cathartic,  in  cerebral  congestion,  hydrocephalus,  etc. 

152.  Sulphite  of  Sodium. 

g.. — Sulphite  of  Sodium,  two  to  four  drachms;  Mucilage  of  Gum 
Arabic,  six  fluidounces ;  mix.  Take  a  tablespoonful  every  three  or 
four  hours. 

In  zymotic  diseases,  as  glanders,  etc. 

153.  Assafoetida  and  Expectorants. 
g^  .—Syrup  of  Ipecac,  two  fluidrachms  and  a  half;  Syrup  of  Squills, 
three  or  four  fluidrachms ;  Mixture  of  Assafoetida,  enough  to  make 
two  fluidounces ;  mix.     Give  one  or  two  teaspoonfuls  at  once. 
In  hooping-cough. 

154.  Belladonna  Mixture. 
g: . — Extract  of  Belladonna,  one  grain ;  Mucilage  of  Gum  Arabic, 
two  fluidounces;  mix.     Give  one  or  two  teaspoonfuls  thrice  daily. 
In  severe  hooping-cough. 

155.  Fluid  Ext't-act  of  Hyoscyamus. 

g.  — Fluid  Extract  of  Hyoscyamus,  half  a  fluidrachm ;  Orange- 
flower  Water,  or  Camphor  Water,  four  fluidounces ;  mix.  Give  from 
a  teaspoonful  to  a  tablespoonful,  every  three  or  four  hours. 

In  severe  hooping-cough. 

156.  Cfhlorute  of  Potassium. 

R. — Chlorate  of  Potassium,  two  drachms  and  a  half;  Peppermint 
Water,  four  fluidounces ;  dissolve.  Take  a  tablespoonful  every  three 
hours. 

In  diphtheria,  ulcerated  sore  mouth,  etc. 

157.  Chlorate  of  Potassium  and  Chloride  of  Iron. 
^  .—Chlorate  of  Potassium,  two  drachms ;  Tincture  of  Chloride  of 
Iron,  one  fluidrachm ;  Simple  Syrup  and  Peppermint  Water,  each  two 
fluidounces ;  mix.     Take  a  tablespoonful  every  three  hours. 
In  diphtheria. 

158.  Creasote  in  Glycerin. 
Dissolve  four  to  eight  drops  of  Creasote  in  two  fluidounces  of 
Glycerin,  diluted  with  an  equal  bulk  of  Water. 
Use  as  gargle. 

159.  Quinine  Pills. 
R. — ^Divide  twenty  grains  of  Sulphate  of  Quinine  into  ten  or  twenty 
pills.     Take  one  as  required. 
For  intermittent  fever,  etc. 


FORMULA.  619 

ICO.  Sulphate  of  Cinchonia  Solution. 

R. — Siilp?iate  of  Cinclionia,  forty-eight  grains;  Aromatic  Siil|)l)uric 
Acid  (Elixir  of  Vitriol),  a  tliiidrachm  and  a  half;  Compound  Tinc- 
ture of  Cardamom,  halt'  atlmdounco;  Peppermint  Water,  enough  to 
make  four  tluidounces.     Take'  a  teaspoonfid  or  two  as  required. 

For  intermittent  fever,  etc. 

IGl.  SiiJpliate  of  Cinchonia  Pills. 
R. — Sulphate  of  Oiuchonia,  two  scruples;  divide  into  twenty  pills. 
Take  one  as  required. 

As  a  tonic,  or  for  intermittent. 

1G2.  Quinine  and  Iron  Pills. 

R. — Sulphate  of  Quinine,  a  scruple;  Pill  of  Carbonate  of  Iron 
(Vallet's  Mass),  a  drachm;  mix,  and  divide  into  twenty  pills.  Take 
one  three  or  four  times  daily. 

An  admirable  tonic,  after  intermittent,  etc. 

163.  Capsicum  Pills. 
R . — Powdered  Capsicum,  a  drachm ;  divide  into  twelve  pills.    Take 
one  every  hour  or  two. 
In  the  chill  of  pernicious  fever. 

164.  Calomel,  Quinine,  Camphor,  and  Opium. 

R. — Calomel,  Quinine,  and  Camphor,  each  eight  grains;  Opium, 
two  grains ;  divide  into  eight  pills.  Take  one  every  half  hour,  hour, 
or  two  hours. 

In  pernicious  fever. 

165.  Nitro-muriatic  Acid,  Nitre,  and  Camphor  Water. 
R . — Xitro-muriatic  Acid,  half  a  fluidrachm ;  Sweet  Spirit  of  Nitre, 
half  a  fluidounce;  Camphor  Water,  five  and  a  half  fluidounces;  dis- 
solve.    Take  a  tablespoonful  every  two  or  three  houi-s. 
In  low  fevers. 

166.  Nitric  Acid. 
R. — Nitric  Acid,  forty  drops;  Water,  eight  fluidounces;  dissolve. 
Take  one  or  two  tablespoonfuls  every  three  hours. 
In  typhus  fever. 

167.  Guaiacum. 
R. — Tincture  of  Guaiacum,  two  fluidounces.     Take  a  teaspoonful 
thrice  daily,  in  water. 
Por  chronic  rheumatism. 

168.  Nitre,  Sulpjhur,  and  Guaiacum. 

R. — Nitrate  of  Potassium,  an  ounce  and  a  half;  Sulphur,  an  ounce; 
Guaiacum,  half  an  ounce;  add  two  nutmegs,  and  a  half  pint  of  mo- 
lasses ;  mix.     Take  a  teaspoonful  or  two  at  night. 

For  chronic  rheumatisin. 

169.  Iodide  of  Mercury. 

R. — Green  Iodide  (Protiodide)  of  Merciuy,  twelve  grains;  Con- 
serve of  Roses,  a  scruple ;  divide  into  twelve  or  twenty-four  pills. 
Take  one  twice  daily. 

In  syphilis. 


620  FORMULiE. 

170.  I)onovan''s  Solution. 
B . — Liquor  of  the  Iodide  of  Mercury  and  Arsenic,  half  a  fluidounce. 
Take  from  three  to  five  drops  twice  or  thrice  daily. 
In  secondary  syphilis,  obstinate  cutaneous  eruptions,  etc. 

171.  Injection  for  Gonorrhoea, 

R. — Sulphate  of  Zinc,  four  grains;  "Water,  two  fluidounces;  dis- 
solve. 

Use  once  daily. 

172.  Injection  for  Gonorrhoea. 

R . — Solution  of  Subacetate  of  Lead  (Goulard's)  half  a  drachm  to  a 
drachm ;  Water,  four  fluidounces. 
Use  once  daily. 

173.  Injection  for  Gonorrhoea. 

R . — Chloride  of  Zinc,  two  grains ;  Glycerin  and  Water,  each  a 
fluidounce;  dissolve. 

Use  once  daily. 

174.  Copaiba  Mixture. 

R . — Copaiba,  half  a  fluidounce ;  Compound  Spirit  of  Lavender,  two 
fluidrachms ;  Sugar  and  Gum  Arabic,  each  two  drachms ;  Peppermint 
Water,  enough  to  make  six  fluidounces.  Take  a  tablespoonful  thrice 
daily. 

In  gonorrhoea. 

175.  Cuhehs  Mixture. 

R . — Oil  of  Cubebs,  two  drachms ;  Sweet  Spirit  of  Nitre,  half  a 
fluidounce;  Sugar  and  Gum  Arabic,  each  two  drachms;  Peppermint 
Water,  enough  to  make  six  fluidounces ;  mix.  Take  a  tablespoonful 
thrice  daily. 

In  gonorrhcea. 

176.  LugoVs  Solution. 

R . — Iodine,  six  drachms ;  Iodide  of  Potassium,  a  troyounce  and  a 
half;  Distilled  Water,  a  pint;  dissolve.  Dose,  five  or  six  drops,  twice 
daily,  in  water. 

In  scrofulous  affections. 

111.  Glycerole  of  Zinc. 
R. — Oxide  of  Zinc,  half  a  drachm;  Bower's  or  Price's  Glycerin, 
four  fluidounces;  mix.     Apply  externally,  as  an  emollient.     Shake 
before  using  it. 

178.  Cold  Cream  with  Zinc. 

R. — Acetate  of  Zinc,  two  grains,  dissolved  in  one  fluidrachm  of 
Rose  Water;  mix  with  one  ounce  of  Ointment  of  Eose  Water  (Cold 
Cream). 

Apply  externally,  for  erythema. 

179.  Lead  Ointment. 
R. — Carbonate  of  Lead,  four  grains ;  Glycerin,  a  fluidrachm ;  Simple 
Cerate,  one  ounce ;  mix. 
For  chronic  erythema,  etc. 


F0RMULJ3.  621 

180.  Ghjccrole  of  Lead. 

31. — Carbonate  of  Lead,  oue  draclun;  Glycerin,  fotir  fluidounces; 
mix. 

As  a  local  application  for  ophthalmia  {to  the  outside  of  the  lids  with 
a  hair  pencil),  inflamed  hemorrhoids,  erysipelas,  periostitis,  etc, 

181.  Ointment  of  Oxide  of  Zinc. 
R. — Oxide  of  Zinc,  two  dracLins;  Lard,  one  ounce,  mix.     Apply 
locally,  for  eruptions  on  the  face,  etc. 

182.  Cohhicum  and  Ipecacuanha. 
R. — Wine  of  Colcliiciim  Root,  and  Wine  of  Ipecac,  each,  two  flui- 
drachms ;  mix.     Take  twenty  drops,  in  water,  thrice  daily. 
In  pustular  diseases  of  the  sl:in. 

183.  Ointment  of  8idphn,ret  of  Potassium. 
R . — Sulphide  of  Potassium,  and  Carbonate  of  Sodium,  each,  two 
drachms;  Lard,  two  ounces ;  mix. 
For  tinea  capitis,  etc. 

184.  Sulphite  of  Sodium  and  Glycerin. 

R. — Sulphite  of  Sodium,  two  ounces;  Glycerin,  four  fluidounces; 
Water,  enough  to  make  a  pint ;  mix. 

Use  as  lotion,  in  chronic  diseases  of  the  skin. 

185.  Stimulating  Embrocation. 

R . — Aromatic  Spirit  of  Ammonia,  Spirit  of  Rosemary,  and  Glycerin, 
each  a  fluidounce ;  Tincture  of  Cantharides,  three  fluidrachms*  Rose 
Water,  enough  to  make  eight  fluidounces;  mis. 

For  the  scalp,  in  premature  baldness. 

186.  Cantharides  and  Castor  Oil  Pomade. 

R.  —Balsam  of  Tolu,  two  drachms;  Oil  of  Rosemary,  twenty 
minims;  Tincture  of  Cantharides,  two  fluidrachms;  Castor  Oil,  four 
fluidrachms;  Lard,  an  ounce  and  a  half;  mix. 

For  premature  baldness. 

187.  Ointment  of  White  Precipitate. 

R. — Ammoniated  Mercuiy,  one  scruple;  Glycerin,  a  fluidrachm ; 
Oil  of  Bitter  Almonds,  three  drops;  Lard,  or  Simple  Ointment,  an 
ounce;  mix. 

For  acne  rosacea,  etc. 

188.  Iodide  of  Sulphur  Ointment. 
R. — Iodide  of  Sulphur,  one  scruple;  Lard,  one  ounce:  mix. 
For  army  itch,  etc. 

189.  Asti'ingent  Powder. 
R. — Powder  of  Krameria,  half  an  ounce;  Prepared  Chalk,  two 
drachms ;  Dry  Starch,  an  ounce  and  two  drachms ;  mix. 
To  be  dusted  on  the  skin  in  eczema,  lichen  agrius,  etc. 


622  FORMULA. 

190.  Juniper  Tar  Soap. 
R. — Oil  of  Juniper  (Huile  de  Cade),  Soft  Soap,  and  Alcohol,  each 
a  fluidounce;  mix. 
,    Apply  as  local  alterative,  in  obstinate  skin  diseases. 

191.  Anti-Pruriginous  Lotion. 
R. — Oil  of    Juniper,  and  Alcohol,  each  a  fluidounce;  Water,  six 
fiuidounces;  mix. 

For  itching  of  the  skin  in  prurigo  senilis,  etc. 

192.  Acid  Lotion. 
R. — Hydrochloric  Acid,  twenty  drops;  Water,  four  fiuidounces; 
dissolve. 

For  obstinate  itching. 

193.  Lotion  of  Blue  Vitriol. 
B:. — Sulphate  of  Copper,  six  grains;  Elderflower  Water,  two  fluid- 
ounces;  dissolve. 

Use  as  lotion  for  chronic  erythema,  etc. 

194.  Lotion  of  Corrosive  Sublimate. 
g.. — Bichloride  of    Mercury,  four  grains;  Alcohol,  and  Distilled 
Water,  each  a  fluidounce  ;  dissolve. 
Infavus,  etc.,  as  parasiticide. 

195.  Astringent  and  Sedative  Lotion. 
R . — Oreasote,  eight  drops ;  Tincture  of  Krameria,  two  fluidrachms ; 
Hydrocyanic  Acid,  eight  drops;  Distilled  Water,  four  fiuidounces:  mix. 
In  irritative  and  obstinate  skin  diseases. 

196.  Sedative  Lotion. 
R. — Cyanide  of  Potassium,  fifteen   grains;  Water,  eight   ounces; 
dissolve.     Apply  externally.     It  should  be  kept  in  a  dark  place. 
For  lichen  or  prurigo. 

197.  Sidphuro-alkaline  Ointment. 
R. — Two  drachms  of  Sulphur;  one  drachm  of  Carbonate  of  Potas- 
sium ;  one  ounce  of  Lard ;  mix. 
For  itch. 

198.  Iodide  of  Potassium  and  Glycerin. 
R . — Iodide  of  Potassium,  half  an  ounce ;  Glycerin,  two  fiuidounces ; 
mix.     Use  as  lotion. 

For  scabies,  army  itch,  etc. 

199.  Iodide  of  Potassium  and  Iodide  of  Sulphur. 
R . — Iodide  of   Potassium,  half  an   ounce ;  Iodide   of   Sulphur,  a 
drachm ;  Glycerin  and  Rose  Water,  each  two  fiuidounces ;  Oil  of  Bit- 
ter Almonds,  three  drops;  mix. 
For  itch,  etc. 

200.  Ointr)%ent  of  Carbonate  of  Potassium. 
R . — Carbonate  of  Potassium,  one  drachm ;  Glycerin,  one  fluidrachm ; 
Lard,  an  ounce ;  mix. 
For  eczema,  herpes,  etc. 


FORMUI.iE.  623 

201.  Aloes  Pills. 

R. — Powder  of  Aloes,  one  to  two  scruples:  Oil  of  Cloves,  four 
drops;  mix,  aiul  divide  into  twenty  pills.  Take  one  twice  or  thrice 
daily. 

jFbr  amenon-hnea. 

202.  Aloes  and  Iron. 

R. — Aloes,  twenty  grains;  Quevenne's  Metallic  Iron  (per  hydrogen), 
half  a  draclnn;  Oil  of  Cloves,  three  drops;  mix,  and  divide  into 
twenty  pills.     Take  one  thrice  daily. 

I'or  amenorrhcea. 

203.  Cav7phor,  Lavender,  Paregoric,  and  Ginger. 
R. — Spirits   of    Camphor,    one  fluidrachm ;  Paregoric,    two   flui- 
drachms;  Tinctiire  of  Ginger,  half  a  fluidrachm;  Compound  Spirit 
of  Lavender,  half  a  fluidounce ;  Water,  enough  to  make  two  fluid- 
ounces;  mix.     Take  a  dessertspoonful  every  hour  or  two. 
In  dysmenorrhcea. 

204.  Alum  Lotion. 
R , — Alum,  two  drachms ;  Water,  eight  fluidounces  ;  dissolve.    Inject 
into  the  vagina,  once  or  twice  daily. 
For  leucorrhcea. 

205.  Glycerole  of  Tannin. 
R. — Tannic  Acid,  one  ounce;  Glycerin,  four  fluidounces;  mix,  and 
dissolve  by  a  gentle  heat.     Inject  daily. 
For  ozoena,  gonorrhcea,  or  leucorrhcea. 

20G.  Santonin. 
R. — Santonin,  half  a  drachm;  divide  into  twelve  pills.     Take  one 
twice  daily. 

An  excellent  vermifuge. 

207.  Senna  and  Pink-Boot  Infusion. 

R. — Leaves  of  Senna,  and  Eoot  of  Spigelia,  each  half  an  ounce; 
Boiling  Water,  a  pint  and  a  quarter;  infuse,  covered,  for  two  hours. 
Take  a  wineglassful  morning  and  night. 

A  good  vermifuge. 

208.  Fluid  Extract  of  Senna  and  Spigelia. 
R. — Fluid  Extract  of  Senna  and  Spigelia,  a  dessertspoonful ;  take 
it  in  the  morning,  on  an  empty  stomach. 
For  worms. 

209.  Suppository  of  Santonin. 
R. — Santonin,  twelve  grains;  Cacao  Butter,  a  sufficient  quantity  to 
make  four  suppositories;  mix,  and  divide.     Introduce  one  into  the 
bowel  at  bedtime. 

For  seat-worm^,  a  very  efficient  remedy. 

210.  Corrosive  Sublimate  Lotion. 
R. — Corrosive  Chloride  of  Mercury,  a  scruple;  Water,  four  fluid- 
ounces  ;  dissolve.     Use  as  a  wash. 
To  destroy  lice. 


624  FOEMUL^. 

211.  Coccidus  Indicus. 
R. — Seeds  of  Oocculus  Indicus,  eighty  grains;  Prepared  Lard,  an 
ounce.     Bruise  the  seeds  well  in  a  mortar,  and  mix  with  the  lard. 
To  destroy  lice. 

212.  Carholic  Acid  and  Glycerin. 
R. — Oarbolic  Acid,  one  or  two  drachms;  Glycerin,  afluidounce; 
"Water,  enough  to  make  eight  fluidounces ;  mis.     Use  as  a  lotion. 
To  destroy  lice,  or  relieve  pruritus. 

213.  Carbolic  Acid  Gargle. 

R. — Oarbolic  Acid,  twenty  minims;  Acetic  Acid,  half  a  drachm; 
Honey,  two  drachms;  Tincture  of  Myrrh,  two  drachms;  Water, 
enough  to  make  six  fluidounces.  Mix  together  the  acids  first,  and 
then,  gradually,  the  honey  and  water. 

In  diphtheria. 

214.  Carholated  Glycerin. 

R. — One  fluidounce  of  Oarbolic  Acid  (melted) ;  nine  fluidounces  of 
Bower's  or  Price's  Glycerin.  Mix  over  a  water-bath  at  120°  Fahr., 
stirring  until  incorporated.  Use  as  injection,  in  ozosna,  etc.,  diluted 
with  ten  or  twenty  times  its  bulk  of  water. 

215.  Hebra'^s  Petroleum  Unguent. 

R . — Petroleum  and  Alcohol,  each  one  ounce ;  Balsam  of  Peru,  one 
drachm ;  Oil  of  Eosemary  and  Oil  of  Lavender,  each  fifteen  minims. 
To  be  applied  externally. 

JFor  itch. 

MISCELLANEOUS  PRESCRIPTIONS. 

216.  Syrup  of  Iron,  Quinine,  and  Strychnia. 

R. — Ferri  Sulphatis,  5^;  Sodii  Phosphatis,  5'^]~SJi  Quinige  Sul- 
phatis,  gr.  cxcij ;  Acidi  Sulphurici  Diluti,  quantum  suflicit;  Aquae 
Ammonige,  quantum  sufiicit ;  Strychnine,  gr.  vj ;  Acidi  Phosphorici 
Diluti,  fgxiv ;  Sacchari  Albi,  gxiv.  Dissolve  the  sulphate  of  iron  in 
one  ounce  of  boiling  water,  and  the  phosphate  of  sodium  in  two  ounces 
of  boiling  water.  Mix  the  solutions,  and  wash  the  precipitated  phos- 
phate of  iron  until  the  washings  are  tasteless.  With  suflicient  diluted 
sulphuric  acid,  dissolve  the  sulphate  of  quinia  in  two  ounces  of  water. 
Precipitate  the  quinia  with  ammonia  water,  and  carefully  wash  it. 
Dissolve  the  phosphate  of  iron  and  the  quinia  thus  obtained,  and  also 
the  strychnia,  in  the  diluted  phosphoric  acid.  Then  add  the  sugar, 
dissolve  the  whole,  and  mix,  without  heat. 

Dose,  a  tablespoonful  thrice  daily,  in  anmmia,  chlorosis,  leueocy- 
thcemia,  etc.     This  is  a  favorite  prescription  with  Dr.  Aitken. 

217.  Chlorodyne. 
R. — Chloroformi  fgss;  ^theris  Sulphurici,  ^xc;  Olei  Menthse 
Piperitas,  gtt.  viij ;  Resinge  Oann-abis  Indicas,  gr.  vj  ;  Oapsici,  gr.  ij. 
Mix,  shake  occasionally,  and  allow  it  to  stand  for  a  few  days.  Also 
Morphise  Muriatis,  gr.  xvj ;  dissolve  by  the  aid  of  heat  in  f5ij  of 
Water ;  to  which,  when   cold,  add   of    Scheele's  Hydrocyanic  Acid, 


FORMULA.  625 

trrjxv;  Perchloric  Acid,  f^j;  of  Simple  Syrup  (or  treacle),  fgij.  Add 
this  gradually  to  the  first  mixture,  and  add  enough  water  to  make  four 
fluidounces  in  all.     Dose,  thirty  minims. 

A  potverful  narcotic,  xvhose  'pretensions,  however,  have  been  exag- 
gerated. 

Dr.  Edward  Smith  has  given  the  following  as  the  recipe  for  chloro- 
dyne : — 

R. — Chloroformi,  f^iv; 

Morph.  Muriat.,  gr.  sx; 

yEther.  Rectificat.,  f5ij ; 

01.  Menth.  Pip.,  tr^viij  ; 

Acid.  ITydrocyan.  Dilut.,  f5iv; 

Tinct.  Capsici,  f^yy, 

Mist.  Acacifis,  f gj . 

TheriaciB^  ad,  fgv. 

218.  Dr.  IIammond''s  Alterative  for  Syphilis. 
R. — Potassii  lodidi,  3j ;  Hydrargyri  Bichloridi,  gr.  vj ;  Aquae,  fo^ij ; 
misce. 

Take  a  tablespoonful  thrice  daily. 
In  syphilitic  rvpia,  etc. 

219.  Ginchonated  Syrup  of  Iron. 
R. — Ferri  Phosphatis,  5J; 
Aquaj,  fojss;  solve. 
Cinchonia3  Sulphatis,  3j; 
Acidi  Sulphuric!  Diluti,  gtt.  xx. 
Aquo3,  foJss;  solve. 
Misce,  et  adde  Syrupi  Aurantii  quantum  sufEcit  ut  fiat  mistura, 
fgiv.     Dose,  a  dessertspoonful,  as  a  tonic. 

220.  Antidote  for  Arsenic. 
R. — Liquoris  Ferri  Tersulphatis  (U.  S.  P.),  et 
Aqute  Ammonias,  aafgiv; 
Aquse,  Oj ;  misce. 
Pour  this  mixture  into  a  small  muslin  bag,  strain  and  wash  it ;  then 
mix  the  precipitate  Avith  half  a  pint  of  water.     Give  a  tablespoonful 
every  five  minutes. 

221.  Compound  Bhvharh  Pills  (U.  S.  P.). 

R. — Pulveris  Radicis  Rhei,  gr.  xxiv;  Aloes,  gr.  xviij ;  Myrrhte,  gr. 
xij ;  Olei  Menthte  Piperita,  "Kij ;  Aquee,  q.  s. ;  misce  bene,  et  divide 
in  pil.  no.  xij. 

A  good,  active  cathartic. 

222.  Compound  Cathartic  Pills  (TJ.  S.  P.). 

R . — Extracti  Colocynthidis  Compositi,  gr.  xvj  ;  Extracti  Jalapaa 
(pulv.),  et  Hydrargyri  Chloridi  Mitis,  aa  gr.  xij;  Gambogiffl,  gr.  ijss; 
Aqupe,  q.  s. ;  misce,  et  divide  in  pil.  no.  xij. 

A  decidedly  active  cholagogue  cathartic. 

1  Molasses. 
53  2P 


626  FORMULA. 

223.  Effervescing  Solution  of  Citrate  of  Magnesium  (IJ.  S.  P.). 

R. — Magnesii  Carbonatis,  5v;  Acidi  Citrici,  S'^ijss;  Syrupi  Limonis 
(vel  Syrupi  Acidi  Oitrici),  fgij;  Aquae  q.  s.  Dissolve  the  citric  acid 
in  four  fluidounces  of  water,  and  add  four  drachms  of  the  carbonate 
of  magnesium,  previously  rubbed  with  three  fluidounces  of  water. 
When  the  reaction  has  ceased,  filter  into  a  strong  glass  bottle  holding 
twelve  fluidounces ;  into  which  the  syrup  has  been  introduced.  Eub 
the  remaining  carbonate  of  magnesium  with  two  fluidounces  of  water, 
pour  into  the  bottle,  cork  quickly,  and  secure  the  cork  with  twine. 
Dose,  from  half  a  tumblerful  to  a  whole  bottle. 

The  least  disagreeable  of  all  cathartic  medicines. 

224.  Hope'' s  Mixture. 
R . — AquEe  Oamphorse,  fgiv ;  Acidi  Mtrosi,  ■njjxsx ;  Tincturas  Opii, 
TT^xx ;  misce. 
Dose,  a  tablespoonful,  every  two  or  three  hours. 
In,  diarrhoea  and  asthenic  dysentery. 

225.  Quinine  and  Chloride  of  Iron. 
R . — Quiniae  Sulphatis,  9j  ;  Tincturse  Ferri  Ohloridi,  f5ijss.     Fiat 
solutio. 

Dose,  fifteen  drops,  in  solution. 

In  diphtheria,  asthenic  erysipelas,  etc. 

226.  Quinine  for  Children. 

R. — Quini*  Sulphatis,  5ss;  Pulveris  Gummi  Acacige,  5ss;  Syrupi 
Zingiberis,  f^iv;  misce. 

Dose,  a  teaspoonful  (one  grain  of  quinine)  or  less,  as  requir^id,  in 
intermittent,  etc. 

227.  Effervescing  Fever  Powders. 

R. — -Acidi  Oitrici,  5^;  divide  in  partes  xij.  Virap  each  of  these  in 
a  white  2)aper. 

R. — Potassii  Bicarbonatis,  3vjss ;  divide  in  partes  xij.  Wrap  each 
of  these  in  blue  paper. 

For  use,  dissolve  the  acid  powder  in  four  tablespoonfuls  of  cold 
water  in  a  tumbler,  and  add,  with  stirring,  the  other  powder.  One 
dose  every  two  or  three  hours  will  be  suitable  in  inflammatory  or 
remittent  fever,  etc. 

228.  Liquid  Substitute  for  Dover'' s  Powders. 
R. — Vini   IpecacuanhEe,    ^xvy,    Tincturfe    Opii,    ""Kxiij;    Spirittis 
JEtheris  Nitrici,  f 5j ;  misce.     To  be  taken  with  water,  at  bedtime. 
For  influenza,  etc. 

229.  Soda  Powders. 
R. — Sodii  Bicarbonatis,  gr.  xxiij. 
R . — Acidi  Tartarici,  gr.  xx. 
Dissolve  each  in  four  tablespoonfuls  of  water,  separately ;  then  pour 
the  solutions  together,  and  drink  while  effervescing.     Gring(H-  syrup 
may  be  added  if  desirable. 


FORMUL-E.  627 

230.  Scudamore''s  Gout  Mixture,  Modified. 
R. — Magnesii  Sulphatis,  gj;  MagnesifB  Optimre,  5ij;  Vini  Colchici 
Hadicis,  £5.1 ;  Aqn{T3  Menthas  Piperitas,  fgx.     Misce. 
Dose,  a  tablespoonful  every  iiour  until  it  operates, 

231.  Black  Wash. 

R. — Plydrargyri  Cliloridi  Mitis,  5j ;  Liquoris  Calcis,  fgiv;  misce. 
Apply  on  lint. 
Apojjular  lotion  for  chancre. 

232.  Yellow  Wash. 

R. — Hydrargyri  Chloridi  Corrosivi,  gr.  xvj  ;  Liquoris  Calcis,  fgviij; 
misce.     For  Chancre.     Apply  on  lint. 

233.  Volatile  Liniment. 
R. — Aqu£B  AraInoni^B  et  Olei  Olivse,  aa  fgss.     Misce. 
To  bathe  an  inflamed  throat,  etc. 

234.  Iodine  Ointment. 
R. — lodinii,  9j ;  Potassi  lodidi,  gr.  iv;  Aqua3,  ^tj^vj  ;  Adipis,    5J- 
Misce. 

For  tumors,  chronic  inflammation  of  joints,  etc. 

235.  Tar  Ointment. 
R. — Picis  Liquidse,  et  Sevi  (vel  Adipis),  aa  gij.     Mix  with  the  aid  of 
heat,  and  strain  through  muslin. 
For  tinea  capitis,  etc. 

236.  Glycerin  Ointment. 

R . — Cetacei,  gss ;  Cerse  Albse,  5j  ;  Ol^i  Amygdalae  Dulcis,  f gij ; 
GlycerinfB,  fgj. 

Melt  the  wax  and  spermaceti  with  the  oil  of  almonds  at  a  moderate 
heat ;  put  these  into  a  mortar,  add  the  glycerin,  and  triturate  until  cold. 

For  chapped  hands,  etc. 

237.  Calomel  and  Carcphor  Ointment. 
R. — Hydrargyri  Chloridi  Mitis,  gr.  viij ;  Camphorse,  9j ;  Glycerinse, 
f 5j ;  Cetacei,  gss;  Adijiis,  gjss.     Misce. 
For  lichen  or  herpes  of  the  face,  etc. 

238.  Sulphur  Ointment. 
R. — Sulphuris,  gj;  Adipis,  gij;  misce. 
For  itch,  etc. 

239.  Lozenges  for  Hoarseness. 
R . — Pulveris  Cubehoa,  gss ;  Aminonii  Chloridi,  gj ;  Olei  Eucalypti, 
f5.i ;  Pulveris  Glycyrrhizae,  Sacchari  Albi,  et  Gummi  Acacise,  aa  5iy  j 
Syrupi  Tolutani,  q.  s. 

Rub  the  powders  thoroughly  together,  then  add  the  oil,  lastly  the 
syrup.     Divide  the  mass  into  lozenges  of  ten  grains  each. 

240.  Liquorice  and  Opium  Lozenges  (U.  S.  P.). 
R. — Opii  Pulveris,  gss;  Glycyrrhizje,  Gummi  Acacise,  et  Sacchari 
AJbi,  aa  gx;  Olei  Anisi,  f3j.     Rub  the  powders  thoroughly  together, 


628  FORMULA. 

then  add  the  oil  of  anise,  and  lastly  add  enough  water  to  form  a  mass. 
Divide  into  lozenges,  each  of  ten  grains. 

Like  "  Wistar's  Cough  Lozenges,"  these  are  very  soothing  to  cough, 
when  taken  at  night. 

241.  Shubarl),  Magnesia,  and  Charcoal. 

R. — Pulveris  Rhei  Radicis,  Magnesiaa  Optimss,  et  Oarbonis  Animalis 
Purificati,  aa  5j  ;  Pulveris  Zingiberis,  5ss ;  misce.  Divide  into  three 
parts,  and  take  one  each  morning,  on  rising. 

For  "biliousness,"  etc. 

242.  Iodide  of  Lead  Ointment 
B  ■ — Plumbi  lodidi,  3j ;  Adipis,  gj  ;  misce. 
For  scrofulous  and  other  tumors, 

243.  Liniment  of  Iodide  of  Potassium. 
R . — Potassii  lodidi,  5j  !  Grlycerinse,  f  gj ;  Tincturse  Saponis  Cam- 
phoratse,  f  giij ;  Olei  Limonis,  gtt.  iv ;  misce. 
For  swollen  joints,  etc. 

244.  Phosphate  of  Manganese. 

R . — Manganesii  Phosphatis,  5j  ;  Acidi  Phosphoric!  Diluti,  ttjJxxv  ; 
Ferri  Phosphatis,  5jss;  Syrup  Cinnamomi,  fgj;  Aquae,  igvij;  misce. 
Take  a  teaspoonful  or  two,  thrice  daily. 

For  anaemia,  hysteria,  etc. 

245.  Stevens^  Saline  Draught. 
B . — Sodii  Ohloridi,  Qiv ;  Potassii  Ohloratis,  gr.  xxviij ;  Sodii  Oar- 
bonatis,  5ij ;  Aquge,  f gyj ;  dissolve.     Take  two  or  three  tablespoon- 
fuls  every  half  hour,  as  the  "saline  treatment"  of  cholera. 

246.  PadcUffe''s  Phosphorus  Pills. 

Take  of  Phosphorus,  six  grains;  Suet,  six  hundred  grains.  Melt 
the  Suet  in  a  stoppered  bottle  capable  of  holding  twice  the  quantity 
indicated.  Put  in  the  Phosphorus,  and,  when  liquid,  agitate  the 
mixture  until  it  becomes  solid.  Roll  into  three-grain  pills,  and  cover 
with  gelatin.  Each  pill  will  contain  one  thirty-third  of  a  grain  of 
phosphorus. 

247.  Trousseau'' s  Syrup  of  Lime. 

Saturate  Simple  Syrup  with  unslaked  Lime.  Or  mix  two  ounces 
of  Lime  and  eight  ounces  of  Sugar  in  a  mortar,  and  pour  over  them 
a  jiint  of  boiling  Water.  Take  half  a  teaspoonful  two  or  three  times 
daily,  in  milk. 

For  rheumatism. 

248.  To  make  a  Sponge -Tent. 

Cut  a  small,  elongated,  conical  piece  of  sponge,  dip  it  in  water, 
and  bind  it  tightly,  with  fine  strong  twine  or  cord,  around  a  central 
wire;  then  dry  it,  remove  the  cord,  coat  it  with  a  mixture  of  equal 
parts  of  wax,  lard,  and  glycerin,  and  fasten  a  piece  of  tape  four  inches 
long  to  the  larger  end.^ 

'  Or,  before  wettiDg  the  sponge,  pass  the  tape  through  it,  from  end  to  end  ;  so  that  both 
ends  of  the  tape  may  be  used  to  withdraw  the  tent. 


FORMULA.  629 

For  uterine  dilataHon,  etc.     Great  care  is  necessary  in  its  use. 

The  dried  stem  of  tlic  sea-tangle  (laiiiinaria  digitata)  is  preferred  for 
the  same  purpose  by  some  practitioners;  and  strips  of  slippery  elin 
bark  by  others. 

249.  Carbolized  Sponge -Tent. 

Prepare  a  piece  of  clean  sponge  as  above,  and,  before  wrapping  it, 
saturate  it  with  a  mixture  of  twelve  grains  of  crystallized  carbolic 
acid  in  an  ounce  of  gum  mucilage. 

Use  as  above. 

250.  Bichardson''s  Stjiptic  Colloid. 

Dissolve,  in  Absolute  Aclohol,  as  much  pure  Tannin  as  it  will  take 
lip  with  several  days'  digestion.  Then  add  enough  washed  Ether  to 
make  the  thick  tinctui-e  quite  fluid.  Satui-ate  this  with  Xyloidin  or 
Gun-cotton.     Lastly,  add  a  few  drops  of  Tincture  of  Benzoin. 

To  be  applied  externally,  for  open  cancer,  hemorrhage,  gangrene. 

251.  Styptic  Colloid^  modified. 

Dissolve  one  di-achm  of  pure  Tannin  in  as  little  Absolute  Alcohol 
as  will  take  it  up,  and  then  add.  it  to  one  fluidounce  of  Collodion. 
Use  externally. 

In  open  cancer,  hemorrhage,  gangrene,  etc. 

252.  Phosphorized  Oil. 

Add  two  parts  of  Phosphorus  to  one  hundred  parts  of  Oil  of 
Almonds;  warm  gently  by  a  water-bath  for  twenty  minutes  in  a  bottle 
almost  closed  from  the  air;  then  cool  and  pour  off.  Dose,  a  portion 
equal  to  one-hundredth  to  one-fiftieth  of  a  grain  of  Phosphorus. 

I7i  locomotor,  ataxy,  neurasthenia,  etc. 

253.  Phosphorus  Pills. 

Take  of  Phosphorus,  2  grains ;  Rice-flour,  200  grains ;  White  Soap, 
250  grains ;  Oil  of  Anise,  and  Glycerin,  each  50  drops.  Mix  carefully, 
and  divide  into  100  pills. 

A  powerful  tonic,  in  nervous  exhaustion. 

254.  Sir  H.  Thompson'' s  Emollient  Injection  for  the  Bladder. 

Dissolve  one  ounce  of  Borax  and  two  fiuidounces  of  Glycerin  in  two 
ounces  of  Water.  Of  this,  for  use,  add.  two  or  three  teaspoonfuls  to 
four  fluidounces  of  warm  Water. 

Inject  into  the  bladder  through  a  catheter ;  in  cystitis,  or  irritable 
bladder. 

255.  Brown- Siquard^s  Prescription  for  Epilepsy. 

Take  of  Iodide  of  Potassium,  one  drachm;  Bromide  of  Potassium, 
one  ounce;  Bromide  of  Annnonium,  two  drachms  and  a  half;  Bicar- 
bonate of  Potassium,  two  scruples;  Tincture  of  Colurabo,  one  fluid- 
ounce  ;  Water,  five  fluidounces ;  dissolve.  Dose,  a  teaspoonful,  with 
a  little  water,  before  each  meal,  and  three  teaspoonfuls  at  bedtime. 

256.  Carbolic  Acid. 
Mix   eight  grains  of  Crystallized.  Carbolic  Acid  with    two   fluid- 
ounces,   each,   of  Cinnamon  Water   and  Mucilage   of   Gum  Arabic. 
Dose,  a  tahlespoonful  every  three  or  four  hours. 
53* 


630  FORMULA. 

257.  Hydrate  of  Chloral. 
Dissolve  half  an  ounce  of  Hydrate  of  Chloral  and  twenty  drops  of 
Essence  of  Peppermint  in  four  fluidounces  of  pure  Glycerin.     Dose,  a 
dessertspoonful  (two  teaspoonfuls)  with  a  tablespoonful  of  water. 

258.  Syrup  of  Lacto-Phospliate  of  Calcium. 

Take  of  Phosphate  of  Calcium,  sixteen  grains;  Lactic  Acid,  thirty- 
three  grains;  Simple  Syrup,  a  iluidounce.  Mix.  Dose,  one  or  two 
teaspoonfuls,  thrice  daily. 

In  rickets,  etc. 

259.  Anti-pruriginous  Lotion. 

Mix  together  two  drachms  of  Borax,  twenty  grains  of  Hydrochlorate 
of  Morphia,  half  a  drachm  of  Hydrocyanic  Acid,  one  fluidounce  of 
Glycerin,  and  eight  fluidounces  of  Rose  Water  (or  Distilled  Water). 

Use  as  a  wash  in  pruritus  vagince,  etc. 

260.  Carbolic  Liniment. 

Take  of  Carbolic  Acid,  one  fluidounce ;  Liniment  of  Camphor  (satu- 
rated solution  of  Camphor  in  Olive  Oil),  three  fluidounces.  Mix  well 
together.     Apply  with  camel's-hair  pencil. 

For  neuralgia,  inflamed  corns,  bunions,  etc. 

261.  Lead,  Carbolic  Acid,  and  Glycerin. 

Take  of  Carbolic  Acid,  half  a  fluidounce ;  Solution  of  Subacetate  of 
Lead  (Goulard's  Extract),  one  fluidrachm;  Glycerin,  enough  to  make 
a  four  ounce  mixture.     Apply  with  a  large  camel's-hair  pencil. 

For  inflamed  corns,  bunions,  etc. 

262.  Salicylic  Acid. 

Take  of  Salicylic  Acid,  one  drachm;  Citrate  of  Ammonia,  one 
drachm;  Glycerin,  two  fluidrachms;  Brandy,  six  fluidrachms.  Dis- 
tilled Water,  five  fluidounces.  Dissolve.  Dose,  one  or  two  table- 
spoonfuls. 

For  acute  inflammatory  rheumatism. 

263.  Liquor  Fids  Alko2inus, 
Take  of  Tar,  two  fluidrachms;  Caustic  Potassa,  one  drachm ;  Water, 
five  drachms.     Mix  together,  and  use  diluted. 
For  chronic  eczema,  etc. 

264.  Acid  Syrup  of  Iron. 

Take  of  Tincture  of  Chloride  of  Iron,  three  fluidrachms;  Dilute 
Phosphoric  Acid,  half  a  fluidoimce;  Syrup  of  Lemons,  three  fluid- 
ounces.     Mix.     Dose,  a  dessertspoonful. 

An  agreeable  tonic,  for  ancemia,  etc. 

265.  Meigs''  Aromatic  Syrup  of  Galls. 

Take  of  Pialverized   Galls,  half  an   ounce;  Pulverized  Cinnamon, 

two  drachms;  Pulverized  Ginger,  half  a  drachm;  Best  Brandy,  half  a 

pint.     Mix,  and  leave  the  mixture  to  stand  in  a  warm  place  for  two 

hours.     Then  burn  ofi"  the  brandy,  holding  lumps  of  sugar  in  the  flame. 


FORMULAE.  631 

Strain  tliroiij^li  filtering  i)ai)er.     Dose,   15  to  40  drops  every  three 
hours. 

For  infantile  diarrhcea. 

2GG.  Squihb''s  Cholera  Mixture. 
Take  of  Laudanum,  Tincture  of  Capsicum,  and  Spirits  of  Caniplior, 
each  a  Huidraclim;  Ciiloroform,  tliree  tluidraclnns;  Alcoliol,  enough 
to  make  a  tluidounce.     Mix.     Dose,  20  to  40  minims. 

2G7.  ChurchilVs  Hypophosphites. 
Dr.  F.  Cimrohill  recommends  a  formula,  which  he  calls  "Liquor 
Ferri  Ilypophospliitis  Compositus,"  and  of  which  the  following  is  the 
percentage  composition: 

Ferrous  hypo])hosphite       ....  2.T7 

Calcium  hypophosphite      ....  3.5 

Sodium  hypophosphite        ....  3.5 

Magnesium  hypophosphite  .         .         .  1.99 

Hvpophosphorous  acid       ....  1.66 

Water 86.58 


100.00 
One  fluidrachm  is  equal  to  6.7  grains  of  the  mixed  salts. 
In  phthisis,  etc, 

268.  Basham^s  Mixture. 

Take  of  Liquor  of  Acetate  of  Ammonium,  six  fluidounces ;  Acetic 
Acid,  three  drachms;  Tincture  of  Chloride  of  L-on,  iive  drachms; 
Alcohol,  two  fluidounces;  Syrup  and  Water,  each  four  fluidounces. 
Mix. 

Dose,  a  teaspoonful  three  or  four  times  a  day. 

In  ancemic  dropsy,  etc. 

269,  Four  Chlorides  (A.  H.  Smith). 

Take  of  Corrosive  Sublimate,  one  or  two  grains ;  Solution  of  Chloride 
of  Arsenic,  a  fluidounee;  Tincture  of  Chloride  of  Iron,  and  Dilute 
Hydi'ochloric  Acid,  each  four  fluidrachms;  Simple  Syrup,  three  fluid- 
ounces;  Water,  enough  to  make  in  all  six  fluidounces.  Dose,  a 
dessertspoonful,  in  water,  after  each  meal. 

A  poiver/ul  alterative  ;  e.  g.,  in  chlorosis,  ancemic  syphilitic  cases,  etc. 

270.  Pills  of  Phosphorus,  Iron,  Quinine,  and  N'ux  Vomica. 

Take  of  Phosphoras  (for  each  pill)  one  hundredth  of  a  grain ;  PiU 
of  Carbonate  of  Iron  (Vallet's),  two  grains;  Sulpliate  of  Quinine, 
one  grain ;  Extract  of  Nux  Vomica,  one  quarter  of  a  grain.  To  be 
taken  thrice  daily. 

A  powerful  nervine  tonic. 

271.  Bla^id^s  Pills  of  Iron. 
Take  of  Dried  Sulphate  of  Iron,  and  Carbonate  of  Potassium,  each 
two  drachms;  Simple  Syrup,  a  sufficient  quantit}^  to  make  a  mass. 
Divide  into  48  pills.     One  to  be  taken  three  or  four  times  daily. 


682  FORMULA. 

272.  Phosphorated  Cod  Liver  Oil  (Squibb). 

Take  of  Phosphorus,  one  grain ;  Cod  Liver  Oil,  ninety  grains.  Mix, 
with  great  care.  Dose,  one  or  two  drops,  in  a  tablespoonful  of  Cod- 
Liver  Oil. 

273.  Phosphorus  Mixture. 

Dissolve,  with  gentle  heat,  one  grain  of  Phosphorus  in  five  fluid- 
ounces  of  Absolute  Alcohol.  Mix  together  one  fluidrachm  of  Essence 
of  Peppermint,  two  fluidrachms  of  Alcohol,  and  a  fluidounce  and  a 
half  of  Glycerin.  Add  this  mixture  to  the  Solution  of  Phosphorus 
in  Alcohol,  while  it  is  warm.     Dose,  20  to  30  minims. 

274.  Gregory'' s  Powder. 
Mix  together  two  ounces  of  Rhubarb  with  one  ounce  of  Ginger 
and  six  ounces  of  Magnesia.    Dose,  about  a  teaspoonful ;  as  a  stomachic 
laxative. 

276,  Compound  Senna  Powder  (Blackwell). 
Take  of  Pulverized  Senna,  Washed  Sulphur,  and  White  Sugar,  each 
half  an   ounce;  Pulverized  Fennel  Seed,  and  Pulverized  Liquorice, 
each  two  drachms.     Mix.     Dose,  a  teaspoonful. 
A  moderate  laxative. 

276.  Iodoform  with  God-Liver  Oil. 
Take  of  Iodoform,  four  grains ;  Cod  Liver  Oil,  three  ounces  and  a 
quarter  (by  weight) ;  Aniseed  Oil,  twenty-five  drops.     Mix.     Dose, 
from  a  teaspoonful  to  a  tablespoonful. 

277.  Bitter  Syrup  of  Iodide  of  Potassium. 
Take  of  Iodide  of  Potassium,  one  ounce;  Tincture  of  Quassia,  and 
Simple  Syrup,  each  half  a  fluidounce.     Dose,  a  quarter  to  a  half  a 
teaspoonful. 

278.  Iodide  of  Potassium  with  Digitalis. 
Take  of  Iodide  of  Potassium,  half  a  drachm ;  Tincture  of  DigitaHs, 
half  a   fluidounce;  Syrup  of  Gum  Arabic,  four  fluidounces.     Mix. 
Dose,  a  dessertspoonful  four  times  daily. 
In  aneurism  of  aorta,  etc. 

279.  Aloes  with  Nux  Vomica. 

Take  of  Extract  of  Nux  Vomica,  five  grains;  Ipecacuanha,  ten 
grains;  Aloes  and  Assafcetida,  each  half  a  drachm.  Mix,  and  divide 
into  twenty  piUs.     One  to  be  taken  at  night. 

For  habitual  constipation. 

280.  Colocynth  and  Nux  Vomica. 

Take  of  Extract  of  Nux  Vomica,  ten  grains;  Pulverized  Black 
Pepper,  one  scruple ;  Compound  Extract  of  Colocynth,  two  scruples. 
Mix,  and  divide  into  twenty  pills.     One  to  be  taken  at  night. 

A  tonic  laxative,  in  obstinate  constipation. 

281.  Quinine  with  Hydrochloric  Acid  (Fothergill). 

Take  of  Sulphate  of  Quinine,  half  a  grain;  Dilute  Hydrochloric 
Acid,  three  drops ;  Orange  Syrup,  twenty  minims ;  Water,  enough  to 
make  two  fluidrachms.     Mix,  for  a  single  dose. 

In  infantile  remiite^it. 


FORMULAE.  6313 

282.  Quinine,  Iron,  and  Chlorate  of  Potassium. 

Take  of  Siili)li!ite  of  (Quinine,  lialf  :i  druclun  ;  Tincturu  of  Chloride 
of  Iron,  throe  riuidrjichins;  Clilorate  of  'Potiisshiiu,  four  druchins; 
Simple  Syriii),  half  a  Huidouu'ce;  Peppermint  AVater,  euougli  to  make 
in  all  two  tinidouncos.  I'ake  a  teaspoonj'al  every  three  or  four  hours  ; 
or  half  a  teanpooiij'id  every  two  hours. 

In  malignant  diphtheria. 

283.  Benzoale  of  Sodium  (Letzerich). 

Take  of  Penzoate  of  Sodium,  four  scruples;  Syrup  of  Orange,  two 
and  a  half  tiuidrachms;  Peppermint  Water  and  Distilled  Water,  each 
a  tluidounce  and  a  half.  Mix.  Dose,  from  a  teaspoonf  ul  to  a  table- 
spoonful,  according  to  age. 

In  diphtheria,  or  scarlet  fever. 

284.  Salicylic  Acid  with  Acetate  of  Potassium. 

Take  of  Salicylic  Acid,  two  drachms  and  two  scruples;  Acetate  of 
Potassiiun,  tivo  drachms  and  one  scruple;  Glj^cerin,  a  tluidounce; 
Water,  enough  to  make  four  iluidounces.     Mis.    Dose,  a  teaspoonful. 

In  rheumatic  fever. 

285.  Salicylic  Acid  with  Bicarbonate  of  Potassium. 

Take  of  Salicylic  Acid,  three  drachms;  Bicarbonate  of  Potassium, 
six  drachms;  Water,  two  fluidounces.  Mix.  Dose,  a  teaspoonful 
•  every  three  hours. 

In  acute  rheumatism. 

286.  Salicylic  Acid  with  Citrate  of  Potassium. 

Take  of  Salicylic  Acid,  foui-  drachms  and  four  scruples;  Citrate  of 
Potassium,  one  ounce;  Glycerin,  four  fluidounces;  Alcohol,  one  fluid- 
ounce  ;  Cinnamon  Water,  enough  to  make  eight  ounces.  Dose,  a 
dessertspoonful. 

In  acute  rheumatism. 

287.  Salicylate  of  Sodium. 

Take  of  Salicylic  Acid,  three  drachms ;  Bicarbonate  of  Sodium,  two 
drachms;  Glycerin  and  Water,  each  two  fluidounces.  Mix.  Dose,  a 
tablespoonful  every  four  hours. 

In  acute  rheumatism. 

288.  Salicylic  Acid  with  Acetate  of  Ammonium. 

Take  of  Salicylic  Acid,  two  drachms ;  Solution  of  Acetate  of  Am- 
monium, and  Water,  each  fom*  fluidounces.  Mix.  Dose,  a  table- 
spoonful. 

In  acute  rheumatism. 

289.  Anti-emetic  Mixture. 
Take  of  Dilute  Hydrocyanic  Acid,  twenty  drops;  Compound  Tinc- 
ture of  Gentian,  three  tiuidrachms;  Subnitrate  of  Bismuth,  one 
drachm ;  Aromatic  Spirit  of  Ammonia,  one  fluidrachm ;  Syrup  of 
Ginger,  a  fluidounce;  Water,  two  fluidounces.  Mix.  Take  a  dessert- 
spoonful at  once. 


634  FORMULA. 

290.  Soda  Mint  Mixture. 
Take  of  Bicarbonate  of  Sodium,  one  drachm ;  Aromatic  Spirit  of 
Ammonia,    two   fluidrachms;   Peppermint  Water,    four  fluidounces. 
Mix.     Take  from  a  teaspoonful  to  a  tablespoonful  at  once. 

291.  Carminative  Mixture. 

Take  of  best  Magnesia,  one  drachm ;  Aromatic  Spirit  of  Ammonia, 
forty  minims ;  Tincture  of  Assafoetida,  a  fluidrachm  ;  Essence  of  Pep- 
permint, fifteen  di'ops;  Syrup  of  Gum  Arabic,  a  fluidounce;  Water, 
enough  to  make  four  fluidounces.  Dose,  a  teaspoonful  to  a  table- 
spoonful. 

I'^or  infants'  colic,  etc. 

292.  Bismuth,  Pepsin,  and  Strychnia  (Pepper), 
Take  of  Subnitrate  of  Bismuth,  and  of  Pepsin,  each  a  drachm  and 
a  half;    Sulphate  of  Strychnia,  one  grain;    Compound  Tincture  of 
Cardamom,  enough  to  make  in  all  four  fluidounces.     Mix.     Take  a 
teaspoonful  thrice  daily,  in  water. 
In  atonic  dyspepsia. 

293.  Nitromuriatic  Acid  loith  Nux  Vomica  (Pepper). 

Take  of  Dilute  Nitromui-iatic  Acid,  and  Tincture  of  Nux  Vomica, 
each  half  a  fluidrachm ;  Compound  Tincture  of  Gentian,  enough  to 
make  in  all  four  fluidounces.  Mix.  Take  a  teaspoonful,  in  water, 
after  each  meal. 

In  atonic  dyspepsia. 

294.  Mercury  with  Iron  (Otis). 

Take  of  Blue  Pill  two  grains ;  Dried  Sulphate  of  Iron,  one  grain. 
One  such  pill  to  be  taken  twice  or  thrice  daily.  They  should  be 
omitted  if  signs  of  salivation  appear. 

In  ancemic  cases  of  syphilis. 

295.  Iron  and  Nvx  Vomica. 
Take   of    Tinctui-e   of   Chloride  of    Iron,   and   Tincture   of    Nux 
Vomica,    each   a  fluidrachm;    Water,    a   fluidounce.     Dose,    a   tea- 
spoonful. 

296.  Compound  Solution  of  Phosphoric  Acid  with  Iron. 

Take  of  Phosphate  of  Iron,  one-half  grain ;  Phosphate  of  Potas- 
sium, one-quarter  of  a  grain ;  Phosphate  of  Magnesium,  half  a  grain ; 
Phosphate  of  Calcium,  three  grains;  Syrupy  Phosphoric  Acid,  six 
and  a  half  minims ;  Water,  enough  to  make  one  fluidrachm :  a  single 
dose.     To  be  taken  thrice  daily. 

For  general  debility,  ancemia,  etc. 

297.  Cantharides  with  Iron. 
Take  of  Tincture  of  Chloride  of  Iron,  fifteen  drops;  Tincture  of 
Cantharides,  five  drops.     Mix.     Take  twice  daily,  in  water. 
For  sexual  exhaustion  and  impotence. 


FORMULA.  635 

208.  Hua  Vomica  and  Phosphorus. 

Tiike  of  Extract  of  Nux  Vomica,  a  quarter  of  a  grain;  Phospliide 
of  Zinc,  one-sixth  of  a  grain;  Extract  of  Gentian,  two  grains.  Mix, 
in  a  pill,  to  be  taken  twice  daily. 

For  impotence. 

209.  Iron  ayul  Digitalis  with  Phosphoric  Acid.* 
Take  of  Tincture  of  Oliloride  of  Iron,  a  tiuidracbm  and  a  half; 
Dilute  Phosplioric  Acid,  two  ttuidrachins;  Tincture  of  Digitalis,  one 
fluidraclun;  Water,  enough  to  make  in  all  one  tliiidounce.  Mix  tirst 
the  Tincture  of  Chloride  of  Iron  and  Phosphoric  Acid,  and  afterwards 
add  the  Tincture  of  Digitalis.  Dose,  half  a  teaspoonful  to  a  tea- 
spoonful. 

In  exophthalmic  goitre,  etc. 

300.  Quinine,  Iron,  and  Nux  Vomica. 

Take  of  Sulphate  of  Quinine,  two  scruples;  Tincture  of  Chloride 
of  Iron,  four  tluidrachms;  Tincture  of  Nux  Vomica,  four  fluidrachins; 
Hydrochloric  Acid,  half  a  tluidrachm;  Simple  Syrup,  one  fluidounce; 
Water,  enough  to  make  three  fluidounces.  Dose,  a  teaspoonful,  thrice 
daily. 

In  ancemia,  neurasthenia,  etc. 

301.  Iron  with  Chloride  of  Am^noniurn  (T.  G.  Stewart). 
For  each  minim  of  Tincture  of  Chloride  of  Iron,  add  half  a  grain 
of  Chloride  of  Ammonium. 

When  iron  does  not  agree  with  the  digestive  system. 

302.  Iron  with  Hydrochloric  Acid  (Fothergill). 
Take  of  Tincture  of  Chloride  of  Iron,  five  minims ;  Dilute  Hydro- 
chloric Acid,  ten  minims.     Take,  in  water,  three  or  four  times  daily. 

303.  Modified  Dover''s  Powder  (Chisholm). 
Substitute  the  Bromide  of  Potassium,  in  equal  quantity,  for  the 
Sulphate  of  Potassium,  in  the  ordinary  formula  for  Dover's  Powder. 

304.  Chloral,  Bromide  of  Potassium,  and  Opium. 

Take  of  Hydrate  of  Chloral,  one  drachm ;  Bromide  of  Potassium, 
one  drachm ;  Laudanum,  one  fluidrachm ;  Simple  Syrup,  half  a  fluid- 
ounce  ;  Cinnamon  Water,  enough  to  make  two  fluidounces.  Mix. 
Dose,  from  a  dessertspoonful  to  a  tablespoonful,  at  night. 

For  insomnia. 

305.  Valerian,  Lupidin,  and  Lactucarium. 

Take  of  Tincture  of  Lupulin,  a  fluidounce ;  Elixir  of  Valerianate 
of  Ammonium,  and  Syrup  of  Lactucarium,  each  half  a  fluidounce. 
Mix.     Dose,  a  teaspoonful  or  two,  at  bedtime. 

For  insomnia,  or  nervous  restlessness  at  night. 


*  This  makes  an  almost  perfectly  clear  solution,  which  may  be  made  entirely  so  by 
filtration. 


636  FORMULA. 

306.  Bromide  of  Potassium  and  Hyoscyamus. 

Tale  of  Bromide  of  Potassium,  half  a  drachm;  Tincture  of  Hyos^ 
cyaraus,  half  a  tluidrachm ;  Camphor  Water,  a  fluidounce.  To  be 
taken  at  bedtime. 

For  chordee  or  spermatorrhoea. 

307.  Anaphrodisiac  (Bartholow). 
Take  of  Tincture  of  Gelsemium,  .one  fluidrachm ;  Tincture  of  Bel- 
ladonna, two  fluidrachms.     Mix.     Dose,  15  drops,  in   water,    thi-ice 
daily. 

308.  Chloral  with  Bromide  of  Potassium. 

Take  of  Hydrate  of  Chloral,  five  grains;  Bromide  of  Potassium, 
twenty  grains ;  Peppermint  Water  and  Simple  Syrup,  each  two  flui- 
drachms.    Mix.     Dose,  from  a  teaspoonful  to  a  tablespoonful. 

For  nervous  restlessness ;  as  night-terrors  in  children. 

309.  Nitre  with  Camphor  and  Ammonia. 

Take  of  Nitrate  of  Potassium,  one  drachm ;  Sweet  Spirit  of  Nitre, 
two  fluidrachms;  Camphor  Water,  a  fluidounce  and  a  half;  Solution 
of  Acetate  of  Ammonium,  enough  to  make  four  fluidounces.  Mix. 
Dose,  a  tablespoonful  every  three  or  four  hours. 

A  calmative  diaphoretic. 

310.  Aconite  with  Nitre  and  Citrate  of  Potassium, 
Take  of  Tincture  of  Aconite  Eoot,  five  minims;  Sweet  Spirit  of 
Nitre,  one   fluidrachm;  Citrate  of   Potassium,  one   drachm;  Water., 
enough  to  make  two  fluidounces.     Mix.     Dose,  a  tablespoonful,  every 
two,  three,  or  four  hours. 
A  sedative  diaphoretic. 

311.  Ipecacuanha  with  Nitre. 

Take  of  Nitrate  of  Potassium,  one  drachm ;  Sweet  Spirit  of  Nitre, 
two  fluidrachms ;  Wine  of  Ipecac,  one  fluidrachm ;  Water,  enough  to 
make  four  fluidounces.   Mix.   Dose,  a  tablespoonful,  every  three  hours. 

A  good  diaphoretic  mixture. 

312.  A  Sedative  Diaphoretic. 

Tako  of  Wine  of  Antimony,  five  drops ;  Tincture  of  Hyoscyamus, 
fifteen  drops ;  Solution  of  Acetate  of  Ammonium,  half  a  fluidounce. 
Mix,  and  take  every  four  or  six  hours. 

313.  Diuretic  Pills. 

Take  of  Squills  and  Digitalis,  each  half  a  drachm  ;  Nitrate  of  Potas- 
sium, one  drachm.  Mix,  and  divide  into  thirty  pills.  Take  one  thrice 
daily. 

314.  Expectorant  Mixture. 

Take  of  Chloride  of  Ammonium,  two  drachms ;  Syrup  of  Senega 
and  Syrup  of  Squills,  each  two  fluidrachms ;  Syrup  of  Wild  Cherry 
Bark,  a  fluidounce  ;  Deodorized  Tincture  of  Opium,  half  a  fluidrachm ; 
Fluid  Extract  of  Liquorice,  two  fluidrachms;  Water,  enough  to  make 
two  fluidounces.  Mix.  Dose,  one  or  two  teaspoonfuls,  every  four 
hours. 

In  chronic  bronchitis. 


FORMULiE.  (iol 

315.  A  Calmative  Expectorant. 

Tiike  of  riiloride  of  i\iiiiiioniiiin,  two  (Iracliin.s;  nofrmann\s  Ano- 
il.vne,  six  tiuidnu'lims;  Synip.  of  Wild  Cherry  l^ark,  a  fliiidounce; 
('iunplior  Water,  enough  to  iiiake  two  tiuidoiinces.  Mix,  Dose,  a 
dessertspoonful. 

In  chronic  bronchitis,  phthisin,  etc. 

316.  Sedative  Expectorant  Mixture. 

Take  of  Acetate  of  Morphia,  one  grain;  Tincture  of  Bloodroot 
(Sanguinaria),  two  fluidra<-Iims;  Wine  of  Ipecacuanha,  one  fluidraclnn  ; 
Fhiid  Extract  of  Wild  ('lierry  Bark,  lialf  a  tiuidounce;  ttyrup  of 
Senega,  a  tiuidounce  and  a  half:  Syrup  of  Gum  Arabic,  enough  to 
make  four  tluidounces.  Mix.  Take  from  u  dessertspoonful  U)  a  table- 
spoonful  every  8  or  4  liours. 

I'br  bronchial  cotir/h,  etc. 

317.  Sedative  Cough  Mixture. 

Acetate  of  Morphia,  six  grains ;  Cyanide  of  Potassium,  one-fourth 
of  a  grain;  Fluid  Exti-act  of  Wild  Cherry  Bark,  six  tluidounces; 
Syrup  of  Tolu,  two  tluidounces.     Mix.     Take  a  teaspoonful  at  once. 

For  irritative  bronchial  cough,  etc. 

318.  Chloride  of  Amtnonium  Mixture. 

Chloride  of  Ammonium  (Muriate  of  xiniTnonia),  two  drachms ;  Ex- 
tract of  TJquorice,  one  drachm  ;  Vinegar  of  Opium,  half  a  fluidrachm  ; 
Syrup  of  Orange,  two  tluidounces;  Distilled  Water,  four  tluidounces. 
Mix.     Take  a  tablespoonful  thi-ee  or  four  times  daily. 

In  chronic  bronchitis. 

319.  For  Troublesome  Hooping- Cough,  etc. 
Take  of  Hydrate  of  Chloral,  a  scrn[)le;  Wine  of  Ipecacuanha,  two 
fluidrachms;  Orange  Syrup,  half  a  tiuidounce  ;  Mint  Water,  one  fluid- 
ounce.     Mix.     Take  a  teaspoonful  or  two  occasionally. 

320.  Lobelia  and  Hoffmann''s  Anodyne. 

Take  of  Tincture  of  Lobelia,  half  a  fluidrachm;  Compound  Spirit 
of  Ether,  two  fluidrachms  and  a  half;  Camphor  Water,  five  Hui- 
drachms.     Dose,  a  teaspoonful. 

In  asthma,  etc. 

321.  Gallic  and  Sulphuric  Acid  Mixture  (Pepper). 

Take  of  Gallic  Acid,  two  drachms;  Aromatic  Sulphuric  Acid 
(Elixir  of  Vitriol),  one  fluidrachm;  Glycerin,  a  tiuidounce;  Water, 
enough  to  make  six  fluidounces.  Mix.  Dose,  a  tablespoonful  as 
required. 

For  hremoptysis. 

322.  Spigelia,  Senna,  and  Santonin  (J.  L.  Smith). 

Take  of  Fluid  Extract  of  Spigelia  and  Fluid  Extract  of  Senna,  each 
four  fluidrachms;  Santonin,  eight  grains.  Mix.  Dose,  one  or  two 
teaspoonful  s. 

Ati  excellent  vermifuge, 
54 


638  FORMULA. 

323.  Scammony  and  Cream  of  Tartar  (G.  Johnson). 
Take  of  Eesin  of  Scammony,  five  grains ;  Bitai'trate  of  Potassium, 
twenty  grains ;  Ginger,  eight  grains.     Mix.     To  be  talsen  at  once. 
In  urcemia. 

324.  Laxative  Pills. 

Take  of  Resin  of  Podophyllum,  two  grains ;  Extract  of  Hyoscy- 
amus,  six  grains ;  Castile  Soap,  ten  grains.  Mix,  and  divide  into  24 
pills.     Take  one  at  night. 

325.  Laxative  Pills. 

Take  of  Podophyllin,  two  grains;  Exti-act  of  Nux  Vomica,  six 
grains;  Aloes,  twelve  grains;  Extract  of  Gentian,  thirty-six  grains. 
Mix,  and  divide  into  24  pills.     Take  one  at  night. 

326.  For  Diarrhoea. 

Take  of  Aromatic  Sulphuric  Acid  (Elixir  of  Vitriol),  two  flui- 
drachms;  Extract  of  Logwood,  two  drachms;  Paregoric,  half  a  fluid- 
ounce;  Syrup  of  Ginger,  enough  to  make  six  fluidounces.  Mix.  Take 
a  tablespoonful  at  once. 

327.  Bismuth  and  Opium  (J.  L.  Smith). 

Take  of  Deodorized  Tincture  of  Opium,  sixteen  drops;  Subnitrate 
of  Bismuth,  two  drachms;  Simple  Syrup,  half  a  fluidounce;  Water,  a 
tiuidounce  and  a  half.  Mix.  Dose,  a  teaspoonful  for  a  child  one 
year  old. 

In  infantile  summer  diarrhoea. 

328.  Nitrate  of  Iron  and  Columho  (J.  L.  Smith). 

Take  of  Solution  of  Nitrate  of  Iron,  eighteen  drops ;  Tincture  of 
Oolumbo,  two  fluidrachms;  Simple  Syrup,  two  fluidounces.  Mix. 
Dose,  a  teaspoonful  for  an  infant. 

In  protracted  infantile  diarrhcea,  etc. 

329.  For  a  Severe  Cold  in  the  Head. 
Take  of  Hydrochlorate  of  Morphia,  one  grain ;  Subnitrate  of  Bis- 
muth, six   drachms;  Gum  Arabic,  in   powder,  two   drachms.     Mix. 
Use  as  snufE  in  the  course  of  two  or  three  days. 

380.  Benzoic  Acid  with  Copaiba. 

Take  of  Benzoic  Acid,  four  scruples;  Sweet  Spirit  of  Nitre,  half  a 
fluidounce ;  Copaiba,  four  fluidrachms ;  Sugar  and  Gum  Arabic,  each 
two  drachms;  Aniseed  Oil,  ten  drops;  Camphor  Water,  enough  to 
make  eight  fluidounces.     Take  a  tablespoonful  thrice  daily. 

In  inflammation  of  the  bladder,  gonorrhoea,  etc. 

331.  Carbolic  Acid  for  Atomization. 

Take  of  Carbolic  Acid,  thirty-two  grains;  Glycerin,  two  fluid- 
ounces;  Lime-water  six  fluidounces.  Mix.  To  be  sprayed  into  the 
throat. 

In  diphtheria. 


FORMULA.  639 

332.  Carbolic  Acid  with  Chlorate  of  Potassium  (J.  L.  Smith). 

Take  of  Cjirbolic  Acid,  thirty-two  tiraiiis;  Chk)nite  of  Potassium, 
three  t1iii(h-:ichms;  (ilyoerin, ,  three  thiidoiiuces;  Water,  five  fluid- 
ounces.     Mix.     To  he  sprayed  into  the  throat. 

In  diphtheria. 

333.  SalirnUc  Add  for  Alnmization  (J.  L.  Smith). 
Take  of  Salicylic  Acid,  half  a  drachm;  Glycerin,  two  fluidonnces; 
Lime-water,  eifi;'ht  tluidounces.     Mix.     To  he  sprayed  into  the  throat. 
In  diphtheria. 

334.  Gargle  of  Salicylic  Acid  (Letzerich). 

Dissolve  fifteen  fjrains  of  Sahcyhc  Acid  in  thirty  drops  of  Ahsolute 
Alcohol ;  then  dissolve  this  in  eight  fluidounces  of  Distilled  Water. 
Use  as  gargle. 

In  diphtheria. 

335.  Borax  and  Zinc  Wash. 

Take  of  Borax,  twelve  grains;  Sul])hate  of  Zinc,  one  grain;  Cam- 
phor Water,  a  i^uidrachm;  Distilled  Water  a  fluidounce.  To  be 
applied  to  the  eyelids. 

In  ophthalmia  of  neiv-born  infants. 

330.  Borax  Solution. 
Take  of  Borax,  three  grains;  Water,  and  Eose- water,  each  a  fluid- 
ounce.     Mix.     To  be  applied  to  the  cleansed  conjunctiva. 
In  ophthalmia  neonatorum,  early  stage. 

337.  Atropia  vnth  Glycerin. 
Take  of  Sulphate  of  Atropia,  one  grain ;  Glycerin,  half  a'fluidrachm; 
Water,  two  fluidrachms.     Mix.     To  be  dropped  into  the  eye. 
Ii  ophthalmia  neonatorum,  late  stage. 

338.  Benzoin  Gargle. 

Take  of  Componnd  Tincture  of  Benzoin,  two  fluidrachms;  Glycerin, 
half  a  fluidounce ;  Water,  enough  to  make  four  fluidounces.  Mix.  To 
be  used  as  a  gargle. 

In  ulceration  of  the  throat,  fi'om  syphilis  or  laryngeal  phthisis. 

339.  Morphia  Poivder  (Lauder  Brunton). 

Mix  one  grain  of  Sulphate  of  Morphia  with  twelve  grains  of  Pul- 
verized Starch.  Divide  into  six  powders.  One  to  be  blown  through 
a  tube  into  the  larynx. 

1)1  laryngeal  phthisis,  or  syphilitic  sore  throat. 

340,  Chlnrinated  Soda  with  Borax. 

Take  of  Borax  and  Bicarbonate  of  Sodium,  each  two  drachms ; 
Labarraque's  Solution  of  Chlorinated  Soda,  a  fluidrachm;  Glycerin, 
a  fluidounce ;  Water,  enough  to  make  eight  fluidounces.  Mix.  To  be 
sprayed  into  tlie  nostrils. 

In  ozeena. 


640  FORMULA. 

341.  Carholic  Acid  and  Borax  for  Atomization. 

Take  of  Carbolic  Acid,  one  grain ;  Borax  and  Bicarbonate  of  Sodium, 
eacli  two  grains ;  Glycerin,  a  fluidrachm ;  Water,  enough  to  make  a 
fluidounce.     Mix.     To  be  sprayed  into  the  nostrils. 

For  chronic  nasal  catarrh. 

342.  Ap2:)licaUon  for  Chronic  Nasal  Catarrh  (H.  Allen). 

Take  of  French  Gelatin,  a  drachm  ;  dissolve  it  in  a  small  portion 
of  "Water;  then  add  to  it,  of  Glycerin,  ten  drops;  Pulverized  Iodo- 
form, three  drachms  and  a  half;  Carbolic  Acid,  five  grains.  Rub 
together  into  a  smooth  paste.  To  he  applied  to  the  nostril  on  a  pledget 
of  cotton. 

343.  Boracic  Acid  Wool  (Woakes). 

Take  of  Cotton  Wool,  one  drachm;  Glycerin,  ten  minims;  Boracic 
Acid,  one  drachm ;  Alcohol,  six  fluidrachms.  Mix,  saturate  the  wool, 
and  dry  it.     To  be  introduced  into  the  nostrils. 

In  chronic  nasal  catarrh,  etc. 

344.  Ojjium  Wool  (Woakes). 

Take  of  Cotton  Wool,  one  drachm  ;  Glycerin,  ten  minims ;  Lauda- 
num, half  a  fluidounce.  Mix,  saturate  the  wool,  and  dry  it.  To  be 
introduced  into  the  nostrils. 

In  painful  nasal  affections. 

345,  Perchloride  of  Iron  Wool  (Woakes). 

Take  of  Cotton  Wool,  one  drachm ;  Glycerin,  ten  minims ;  Tincture 
of  Chloride  of  Iron,  one  fluidounce.  Mix  the  Glycerin  with  the 
Tincture,  saturate  the  wool  with  the  liquid,  and  dry  it.  To  be  intro- 
"luced  into  the  nostrils. 

Z«i  chronic  nasal  catarrh,  ozcena,  etc. 

346.  Zinc  and  Tar  Ointment  (Bulkley). 
Take  of  Tar  Ointment,  an  ounce;  Oxide  of  Zinc,  two  drachms; 
Cold  Cream  (Ointment  of  Kose-water),  three  ounces.     Mix. 
For  infantile  eczema. 

347.  Ointment  of  Atropia  with  Opium  and  Iodoform. 

Take  of  Sulphate  of  Atropia,  six  grains;  Opium,  twelve  grains; 
Iodoform,  a  drachm ;  Vaseline,  enough  to  make  tlu-ee  ounces.  Mix. 
Apply  externally. 

For  painful  piles,  etc. 

348.  Iodoform  and  Tannic  Acid  (Sturgis). 
Take  of  Tannin  and  Iodoform,  equal   parts;  triturate  them  well 
together.     Apply  the  powder  locally. 
For  chancroidal  ulcers. 

349.  Iodoform  and  Mercury  Ointment. 

Take  of  Oleate  of  Mercury,  half  a  fluidounce ;  Iodoform,  twenty- 
four  grains ;  Oleic  Acid,  a  fluidounce.     Mix.     Apply  externally. 

For  swollen  Joints,  syphilitic  eruptions,  or  parasitic  affections  of  the 
skin. 


F  O  R  M  U  L  iE .  641 

350.  Chloroform  with  Vaseline. 
Mix  top:etlicr  equal  parts  of  Cliloroforin,  Etlicr,  and  Vaseline. 
An  anodyne  liniment,  for  contusions,  sprains,  chronic  rJieuniatism,  etc. 

351.  Lead  Ointment  (Ilebra). 

Mix  together,  with  the  aid  of  heat,  three  ounces  and  six  scruples  of 
Litharjre  and  fifteen  ounces  of  Olive  Oil;  then  add  three  fluidrachras 
of  Oil  of  Lavender. 

A  soothing  unguent,  in  affections  of  the  skin. 

352.  Ointment  of  Oleate  of  Zinc  (Crocker), 
liul)  tosjether  an  oimee  of  Oxide  of  Zinc  and  eip:ht  ounces  of  Oleic 
Acid,  and  then  leave  the  mixture  to  stand  for  two  hours.     Heat  gently 
in  a  water-bath,  and  add,  stirring,  nine  ounces  of  Vaseline. 
A  soothing  unyuent. 

353.  Liniment  of  Chloral  and  Cam^jhor. 

Pulverize  an  ounce  of  Gum  Camphor,  with  aid  of  a  few  drops  of 
rectified  spirit.  Mix  this  with  an  ounce  of  Hydrate  of  Chloral. 
When  tliis  mixture  becomes  liquid,  add  to  it  enough  Glycerin  to  make 
six  fluidounces.     Apply  locally. 

For  neuralgia. 

354.  Croton  Oil  and  Iodine. 

Take  of  Croton  Oil,  half  a  fiuidrachm;  Ether,  one  fiuidrachm; 
Tincture  of  Iodine,  two  fluidrachms  and  a  half.  Mix.  To  be  painted 
upon  the  skin  with  a  camel's-hair  pencil. 

A  counterirritant,  for  chronic  pleurisy,  etc. 

355.  Liniment  for  Neuralgia. 
Take  of  Camphor,  one  ounce;  Hydrate  of  Chloral,  half  an  ounce; 
Chloroform,  a'tiuidounce  and  a  half;  Soap  Liniment,  two  and  a  half 
fluidounces.     Apply  externally. 

356.  Acid  Lotion  of  Corrosive  Sublimate. 
Take  of  Bichloride  of  Mercury,  eight  grains;  Hydrochloric  Acid, 
sixteen  minims;  Water,  eight  fluidounces.     Mix.     Apply  as  a  wash. 
la  lupiis. 

357.  Styrax  and  Sidplmr  Ointment  (Bulkley). 
Take  of  Styrax,  one  or  two  drachms ;  Sulphur  Ointment,  three  or 
four  drachms;  Simple  Cerate,  an  ounce.     Mix.     Apply  externally. 
For  itch. 

35R.  Carhnlic  and  Hydrocyanic  Acids,  xoith  Morphia. 

Take  of  Carholic  Acid,  twelve  grains;  Acetate  of  Morphia,  eight 
grains;  Dilute  Hydrocyanic  Acid,  one  fiuidrachm;  Glycerin,  a  fluid- 
ounce  ;  Water,  enough  to  make  four  fluidounces.  Mix.  To  be  applied 
locally. 

For  troublesome  pruritus. 

359.  Antipruriginous  Ointment  (Bulkley). 
Take  of  Tar  Ointment,  three  drachms;  Belladonna  Ointment,  two 
drachms;    Tincture  of  Aconite  Eoot,  half  a  fluidraclim ;    Oxide  of 
54*  2Q 


642  FORMULiE. 

Zinc,    a   drachm;    Ointment   of  Eose-water    (Cold   Cream),   three 
drachms.     Mix.     Apply  locally. 

360.  For  Pruritus. 
Take  of  Camphor  and  Hydrate  of  Chloral,  each  a  drachm ;  Cold 
Cream   (Unguent.  Aquae  Eos.),   one  ounce.      Mix.      To  be  applied 
locally  (to  a  sound  skin). 

361.  Antipediculous  Wash  (Bulkley). 
Eub  well  together  one  drachm  of  Caustic  Potassa,  two  drachms  of 
Carbolic  Acid,  and  four  fluidrachms  of  Water.     For  local  application. 
To  get  rid  of  lice. 

362.  Sulphite  of  Sodium  and  Carbolic  Acid  (Morrison). 
Take  of  Carbohc  Acid,  half  a  drachm;  Sulphite  of  Sodium,  three 
drachms ;  Water,  six  fluidounces.     Mix.     Apply  externally. 
For  poison-vine  eruption. 

363.  Odorless  Iodoform  Ointment  (Lindemann). 

Take  of  Iodoform,  sixteen  grains ;  Balsam  of  Peru,  thirty  grains ; 
Vaseline,  Lard,  and  Ointment  of  Glycerin,  each  two  drachms.  Mix. 
For  external  application. 

For  scrofulous  tumors,  etc. 

364.  Zinc  with  Huile  de  Cade. 

Take  of  Empyreumatic  Oil  of  Juniper  (oleum  cadini),  of  soft  soap 
(sapo  viridis),  and  of  alcohol,  each  two  ounces;  Oil  of  Lavender,  one 
fluidrachm.     Mix. 

A  stimulating  ointment  for  alterative  effect  in  shin  diseases. 

365.  Vaseline  and  Lead-plaster  (Piffard,  Hebra). 

Take  of  Vaseline  and  Diachylon  Plaster,  equal  parts.  Dissolve  and 
incorporate  them  together  by  aid  of  heat.  Add  a  few  drops  of  bei'- 
gamot  (for  odor).     Apply  externally. 

For  eczema. 

366.  Corrosive  Sublimate  with  Borax  (Bulkley). 

Take  of  Bichloride  of  Mercury,  eight  grains ;  Pulverized  Borax, 
two  drachms;  Dilute  Acetic  Acid,  two  drachms;  Alcohol,  two  fluid- 
ounces;  Water,  enough  to  make  four  fluidounces.  Mix.  Apply 
locally  with  hair  pencil. 

For  chloasma,  or  brownish  discoloration  of  the  face  in  spots  or  patches. 

367,  Iodoform  Paste  (Bronson). 

Take  of  Iodoform,  one  drachm ;  Mucilage  of  Gum  Arabic  and  Gly- 
cerin, each  ten  drops ;  Oil  of  Peppermint  or  Oil  of  Cloves,  one  drop. 
Mix.     For  local  application. 

For  piles,  etc. 

368.  Iodoform  and  Oxide  of  Zinc  with  Benzoated  Vaseline. 
Take  of  Benzoated  Vaseline  (one  ounce  of  Gum  Benzoin  to  five 
ounces  of  Vasehne),  one  ounce ;  White  Wax,  two  drachms  and  a  half ; 


EXPLOSIVK    IMiARMACAL    COMPOUNDS.      643 

Oxide  of  Zinc,  one  ilriicliin  and  one  scruple;  Iodoform,  two  drachms. 
Apjjly  externally. 

For  irritated  ulcers  or  severe  irritation  of  the  skin. 

369,  Ointment  for  Contusions. 
Mix  one  part  of  Iodoform  with  thirty  parts  of  Lard  or  Vaseline. 
Apply  locally  with  gentle  friction.     (A  minim  of  Tincture  of  jMusk 
to  au  ounce  will  deodorize  the  ointment.) 

370.  Chloral  and  Camphorated  Oil. 
Mix  together  one  ounce  of  Hydrate  of  Chloral  with  four  fluidounces 
of  ■  Camphorated  Oil  (Olive  Oil  saturated  with  Gum  Camphor). 
Hub  in  over  affected  muscles  in  trichinosis. 

371,  Carbolic  Acid  and  Glycerin  (Bill,  Bergonzini). 
Mix  together  two  parts  of  Carbolic  Acid  and  one  part  of  Bower's 
or  Price's  Glycerin.     To  be  placed  for  five  minutes  in  contact  with  the 
skin,  as  anaisthetic,  before  opening  an  abscess. 

872.  Lotion  for  Freckles. 
Take  of  Sulphocarbolate  of  Zinc,  two  drachms;    Glycerin,  three 
fluidounces;    Alcohol,  half   a  tluidounce;    Rose  Water  (or  Water), 
enough  to  make  eight  tiuidounces.     Apply  locally. 

373.  For  Sore  NipiDles. 

Take  of  Compound  Tincture  of  Benzoin,  a  sufficient  quantity. 
Apply  it  to  the  nipple  with  a  camel's^hair  pencil  after  each  time  of 
suckling. 

374.  For  Sore  Mpples. 

Take  of  Iodoform,  one  drachm;  Glycerin,  a  fluidounce.  Mix. 
Apply  with  a  camel's-hair  pencil. 

375.  Sup2')Ository  of  Ergot  (Barker). 

Take  of  Aqueous  Extract  of  Ergot,  two  scruples;  Cacao  Butter, 
one  drachm.  Mix,  and  divide  into  twelve  suppositories.  Introduce 
one  into  the  rectum,  twice  or  thrice  daily. 

For  menorrhagia  or  excessive  leucorrhoea. 

376.  Antispasmodic  Suppository. 

Take  of  Opium,  eight  grains;  Camphor,  half  a  drachm;  Extract 
of  Belladonna,  three  grains;  Cacao  Butter,  enough  to  make  six  sup- 
positories.    One  to  be  used  at  night. 

In  painful  piles,  i?}flammation  of  the  bladder,  etc. 

377.  Injection  Brou. 
Take  of  Sulphate  of  Zinc,  eight  grains;  Acetate  of  Lead,  fifteen 
grains ;    Tincture  of  Catechu,  one  drachm ;    Laudanum  and  Water, 
each  three  fluidounces.     Mix,  and  use  for  urethral  injection  in  gonor- 
rhoea. 

EXPLOSIVE  PHARMACAL  COMPOUNDS. 

The  following  combinations  of  medicinal  substances  may  ignite  or 
explode,  if  agitated  or  warmed,  as  by  can-ying  about  the  person : 


644  METEICAL    PRESCRIBING. 

Iodine  with  soap  liniment  or  camphor  liniment ;  chloride  '^r  iodide 
of  ammonium  with  phosphorus,  arsenic,  oil  of  turpentine,  olive  or 
cod-liver  oil ;  concentrated  solution  of  permanganate  or  of  bichromate 
of  potassium  in  alcohol ;  nitromuriatic  acid  with  alcoholic  "  essences  " 
or  alcoholic  extracts;  tannin  with  dry  clilorate  of  potassium  or  hydro- 
chlorate  of  morphia;  hypophosphite  of  calcium  with  chlorate  of 
potassium  and  lactate  of  iron ;  clilorate  of  potassium  with  catechu ; 
golden  sulphuret  of  antimony  with  chlorate  of  sodium;  tincture  of 
perchloride  of  iron  with  chlorate  of  potassium  and  glycerin ;  nitrate 
of  silver  with  essence  of  bitter  almonds ;  oxide  of  silver  in  pills. 

METRICAL  PRESCRIBING. 

Probably  a  generation  may  pass  before  it  will  become  common  to 
write  prescriptions  according  to  the  metrical  or  decimal  system.  But 
that  system  has  so  much  in  its  favor,  and  is  so  largely  employed 
already  in  scientific  works,  especially  upon  the  continent  of  Europe, 
that  it  is  likely,  in  the  end,  to  prevail.  Every  student  will  do  well, 
therefore,  to  familiarize  himself  with  it. 

For  the  immediate  purposes  of  the  practitioner,  a  few  particulars 
only  require  to  be  kept  in  mind.^ 

Accurately  stated,  a  gramme  is  equal  to  15.45234874  grains,  Apothe- 
caries' weight.  A  Kilogi'amme  (1000  grammes)  equals  2.679227  Troy 
pounds. 

A  ciibic  centimetre  is  equal  to  16.231169  minims.  A  litre  equals 
1.056717  wine  quarts. 

When  the  transition  from  our  present  system  to  the  metrical  has 
been  fully  effected,  there  will,  of  course,  be  no  more  difficulty  than 
now,  in  regard  to  the  most  mimite  precision  with  it  in  prescriptions. 
But,  while  becoming  acquainted  gradually  with  the  new  method,  it 
may  for  a  time  be,  with  advantage,  chiefly  resorted  to  for  combina- 
tions of  medicines  in  which  a  small  difference  of  amounts  will  not  be 
important. 

This  being  understood,  approocimative  equivalency  can  be  made 
available  and  convenient,  as  follows:^ 

A  gram  (adopting,  as  preferable,  the  English  spelling)  is  ahout  equal 
to  15  grains.  A  kilogram  is  about  equal  to  2|-  Troy  pounds  (2J 
Avoirdupois  pounds). 

A  citbie  centimeter  is  about  equal  to  15  minims.  A  liter  is  about  a 
quart  measure. 

It  will  be  convenient  also  to  remember  that  a  meter  is  rather  less  1\ 
yard  (39.87079  inches) ;  a  yard  is  somewhat  more  than  9  decimeters; 
a  decimeter  is  not  quite  4  inches ;  a  centimeter  is  nearly  f  of  an  inch ; 
and  a  millimeter  is  somewhat  less  than  -^  of  an  inch. 

From  these  approximations  we  may  proceed  to  accept  4  grams  as 
equal  to  a  drachm,  and  4  cubic  centimeters  as  equivalent  to  ^fiiddrarJim. 
Instead  of  cubic  centimeter,  we  may  call  it  (A.  B.  Tajlor)  Jiuigi^am. 
Then  we  have  a  simple  statement : 

15  grains,        1  gram. 
4  grams,        1  drachm. 
15  minims,      1  fluigrara. 
4  fluigrams,  1  fluidrachm. 

1  See  Oldberg's  "  The  Metric  System  in  Medicine,"  Philada.,  1881. 


METRICAL    PRESCRIBING.  645 

"Whence  these  rules  follow  : 

To  convert  (/ri/iiin  into  grams,  or  minimn  into  linigrams,  divide  ly 
15. 

To  convert  grtinis  into  (/rains,  or  fluigrams  into  minims,  multiply 
ly  15. 

To  convert  grams  into  drachms^  or  fluigrams  into  Jluidrackms,  divide 

To  convert  drachms  into  grams,  oy  Jluidrachms  into  fluigrams,  mul- 
tiplji  by  4. 

With  a  similar  approximation  (8  drachms  being  equal  to  one  ounce) 
wo  nuiy  say : 

To  convert  ounces  into  grams,  or  fluidounces  into  fluigrams,  multijjly 
by  30. 

To  convert  grams  into  drachms,  or  fluigrams  mto  fluidounces,  divide 
ly  30. 

To  prevent  mistakes,  it  will  be  well  to  use  capital  letters  for  the 
metrical  abbreviations  in  prescriptions :  Gm  for  gram,  fGm  for  flui- 
gram.  It  is  actually  unnecessary  to  employ  any  other  terms  in  met- 
rical prescribing ;  as  all  other  differences  may  be  expressed  by  decimal 
notation.  Thus  a  grain  (^  of  a  gram)  is  (approximately)  .06  Gram; 
&  minim  (^  of  a  tiuiGram)  .06  fluiGram.  Half  a  Gram  will  be  writ- 
ten .50  Gm ;  half  a  fluiGram.  .50  fGm ;  etc. 

Tliere  may  be  a  convenience,  however,  sometimes,  in  speaking  or 
writing  of  a  deciGram  {-^  Gram)  and  centiGram  (^^  GramK  It  is 
important  also  to  remember  that  a  deciGram  (dGm)  is  equal  to  1^ 
grain;  and  /y  of  a  fluiGram  (dfGm)  equals  IJ  minim. 

Roughly,  a  teaspoonful  niay  be  counted  as  5  fGm;  a  wineglassful, 
75  fGm ;  a  fluidounce,  30  fGm ;  four  fluidounces,  125  fGm ;  eight 
fluidounces,  250  fGm. 

It  becomes,  with  the  acceptance  of  these  approximate  equivalencies, 
a  matter  of  simple  calculation,  to  translate  a  prescription  in  grains 
and  drachms,  or  minims  and  tiuidrachms,  etc.,  into  one  of  Grams  or 
fluiGrams  and  their  decimal  subdivisions.  It  will,  however,  with 
most  practitioners,  be  difficult  to  write  metrical  prescriptions  with  ease 
and  confidence,  until  they  have  grown  familiar  with  metrical  doses. 
For  an  extended  table  of  these,  the  reader  may  be  referred  to  Dr. 
Oldberg's  work'  upon  this  subject.  The  enumeration  on  the  next  page 
of  doses  of  some  leading  medicines  may  suffice  for  our  present  purpose. 

It  will  be  observed  that  (with  the  exception  of  a  few  new  remedies) 
the  drugs  named  are  such  as  are  likely  to  be  often  used.  Their 
metrical  doses  can  thus,  with  practice,  be  rendered  familiar.  More- 
over, except  tartar  emetic,  extract  of  belladonna,  sulphate  of  morphia, 
extract  of  nux  vomica,  pilocarpin  and  nitrate  of  silver,  their  doses 
are  not  usually  less  than  a  grain  or  a  minim.  Therefore,  the  approxi- 
mative character  of  such  doses,  already  referred  to,  will  not  necessarily 
cause  inconvenience.  This  will  especially  be  the  case,  so  long  as  the 
prescriber  observes  the  important  practical  rule,  to  give,  oi  aW  2}otcer- 
fnl  medicines,  when^/frsi  administered  to  a  patient,  the  smallest  doses 
likelv  to  have  sufficient  cftect. 


1  The  Metric  System  iu  Mediciae,  p.  127. 


64:6 


TABLE    OF    DOSES. 


TABLE  OP  DOSES. 


Medicine. 


Acid,  Nitro-muriatic, 

^ther,  Nitrous,  Spirit  of 

j3llther,  Oomp.  Spirit  of, 

Aloes, 

Ammonium,  Carbonate, 

Ammonium,  Chloride, 

Antimony  and   Potassi- 
um Tartrate 

Assafoetida, 

Belladonna,  Extract, 

Bismuth,  Subnitrate, 

Camphor, 

Camphor,  Spirit, 

Catechu,  Tincture, 

Chloral,  Hydrate, 

Chloroform, 

Colchicum  Root,  Wine, 

Creasote, 

Digitalis,  Tincture, 

Ergot,  Wine, 

Hyoscyamus,  Extract, 

Iron,  Chloride,  Tincture, 

Jaborandi, 

Jaborandi,  Fluid  Extract 

Jalap,  Eesin, 

Kino,  Tincture, 

Lactucarium,  Syrup, 

Lead,  Acetate, 

Lobelia,  Tincture, 

Morphia,  Sulphate, 

Nux  Vomica,  Extract, 

Nux  Vomica,  Tincture, 

Oil,  Cod-Liver, 

Opium, 

Opium,  Tincture, 

Pilocarpin, 

Potassium,  Arsenite,  So-  ' 
lution. 

Potassium,  Chlorate, 

Potassium,  Iodide, 

Quebracho, 

Ehubai'b, 

Squills,  Syrup, 

Silver,  Nitrate, 

Wild  Cherry  Bark,  Syrup 


Apothecaries'    Weights    or 
Measures. 

According  to  Metric 

System. 

2  to    5  minims 

.1 

to 

.5 

fGm 

J  to    1  fluid rachm 

1 

to 

5 

fGm 

^  to    2  tiuidrachms 

2 

to  10 

fGm 

2  to  15  grains 

.1 

to 

1 

Gm 

2  to    5  grains 

.1 

to 

.5 

Gm 

5  to  20  grains 

.3 

to 

1.5 

Gm 

^to    J  grain 

.0015  to 

.015fGm 

3  to  10  grains 

.2 

to 

.75 

Gm 

|-  to    f  grain 

!oi5 

to 

.05 

Gm 

5  to  15  grains 

.3 

to 

1 

Gm 

1  to  10  grains 

.05 

to 

.75 

Gm 

5  to  30  minims 

.3 

to 

2 

fGm 

•|  to    1  fluidrachm 

1 

to 

5 

fGm 

5  to  30  grains 

.3 

to 

2 

Gm 

5  to  60  minims 

.3 

to 

4 

fGm 

10  to  20  minims 

.75 

to 

1.6 

fGm 

1  to    2  minims 

.1 

to 

.2 

fGm 

10  to  20  minims 

.76 

to 

1.5 

fGm 

^  to    1  fluidrachm 

2 

to 

4 

fGm 

1  to    4  grains 

.1 

to 

.4 

Gm 

10  to  30  minims 

.75 

to 

2 

fGm 

5  to  60  grains 

.3 

to 

4 

Gm 

J  to    |-  fluidrachm 

1 

to 

2 

fGm 

2  to    5  grains 

.1 

to 

.3 

Gm 

J  to    1  fluidrachm 

1 

to 

5 

fGm 

1  to    3  fluidrachms 

5 

to  12 

fGm 

J  to    3  grains 

.03 

to 

.2 

Gm 

l5  to  80  minims 

.75 

to 

2 

fGm 

ito    i  grain 

.008 

to 

.015  Gm 

1^  to    1  grain 

.015 

to 

.06 

Gm 

10  to  30  minims 

.75 

to 

2 

fGm 

1  to    4  fluidrachms 

4 

to  16 

fGm 

i  to    1  grain 

.008 

to 

.05 

Gm 

5  to  20  minims 

.3 

to 

1.5 

fGm 

J  to    f  grain 

.008 

to 

.05 

Gm 

2  to  10  minims 

.1 

to 

.75  fGra 

5  to  20  grains 

.3 

to 

1.5 

Gm 

5  to  30  grains 

.3 

to 

2 

Gm- 

10  to  45  grains 

.75 

to 

3 

Gm 

2  to  30  grains 

.1 

to 

2 

Gm 

^  to    1  fluidrachm 

2 

to 

5 

fGm 

J  to    1  grain 

.015 

to 

.05 

Gm 

1  to    2  fluidrachms 

5 

to  10 

fGm 

'^  Approximately  coxD.^&rBdi\  preferring,  when  practicable,  for  metrical  doses,  numbers 
divisible  by  10  or  5.    These  doses  are  for  adults. 


METRICAL    PRESCRIPTIONS.  647 


EXAMPLES  OF   METRICAL  PKESCRIPTIONS. 

R. — Potass.  Chlorat.,  5  Gm. 

A(nue,  (].  s.  ut  ft.  100  Gm. 

M.     Dose,  frt)ni  a  teaspoont'ul  to  a  tablespoonful. 

R. — Vin.  Ipecac,  5  fGra. 

Tiiict.  Opii,  5  fGin. 

Sp.  Ath.  Nitr.,  50  fGra. 

Syrup  Sini]).,  q.  s.  ut  ft.  100  fGra. 

M.     Dose,  a  teaspoonful  witli  water. 

R.— Tinct.  Aconit.  Rad.,  50  fGra. 

Sp.  Ath.  Nitr.,  50  fGra. 

Liq.  Potass.  Oitrat.,  q.  s.  utft.  100  fGra. 
M.     Dose,  a  tablesi^oonful. 

R.— Acid.  SalicyL,  2  Gra. 

Aninion.  Carb.,  3  Gm. 

Cliloral.  Hydr.,  3  Gra. 

Syr.  Simp.,  50  Gra. 

Aqufe,  q.  s.  ut  ft.  100  Gm. 
M.     Dose,  a  dessertspoonful. 

R.— Potass.  lodid.,  10  Gm. 

Syr.  Ferri  lodid.,  20  fGra. 

Tinct.  CalumbiB,  q.  s.  ut  ft.  100  Gm. 
M.     Dose,  a  teaspoonful  with  water. 

R.— Potass.  Bromid.  10  Gra. 

Tinct.  Amnion.  Valerianat,  20  fGm. 

Tinct.  Lupulin,  30  fGra. 

Tinct.  Digital.,  30  fGra. 

Acjufe,  q.  s.  ut  ft.  100  fGm. 
M.     Dose,  a  dessertspoonful. 

R  .—Syr.  Scill.  et 
Syr.  Ipecac,  et 
Tinct.  Opii  Camph.  et 
Glycerin,  aa,  '    25  fGm. 

M.     Dose,  a  teaspoonful. 

Brown  Mixture. 
R.— Ext.  Glych-rhiz., 
Sacch.  et  Acac.  aa, 
Tinct.  Opii  Camph., 
Vin.  Antiinon., 
Sp.  Ath.  Nitr., 
Aquas,  q.  s.  ut  ft. 
M.     Dose,  a  dessertspoonful  to  a  tablespoonful 

R. — Pulv.  Jalapiie, 
Potass.  Bitart., 
M.     Dose,  a  teaspoonful. 


3  Gra. 

3  Gra. 

12  fGra. 

6  fGm. 

3  fGm. 

100  fGm. 
[iful. 

20  Gm. 

80  Gm. 

648  ALIMENTS. 

R.— Pulv.  Opii  et 
Pulv.  Ipecac,  et 

Pulv.  Gum  Oamph.  aa,  5  Gm. 

M.  et  div.  in  pil.  no.  100.     One  to  be  taken  at  a  time. 

R.— Pulv.  Opii,  2  Gm. 

Acid.  Tannic,  15  Gm. 

M.  et  div.  in  pil.  no.  100.     One  to  be  taken  at  once. 

For  Chancre  (Bouchardat). 

R.— FerriPercHorid.,  12  Gm. 

Acid.  Citric,  4  Gm. 

Aq.  Destillat.,  24  Gm. 
M.     Use  as  wash. 

For  Epistaxis. 
R.— Ergotin,  2  Gm. 

Glycerin,  30  fGm. 

M.     Inject  20  drops  at  once,  liypodermically. 

ALIMENTARY  PREPARATIONS. 

Toast  Water. 
Cut  a  slice  of  stale  bread  half  an  inch  thick,  and  toast  it  brown, 
without  scorching.     Pour  over  it  a  pint  of  boiling  water ;  cover  closely 
till  it  cools ;  then  pour  off  and  strain  it. 

Bice  Water. 

Take  of  rice,  two  ounces;  water,  two  quarts.     Boil  it  for  an  hour 
and  a  half,  then  add  sugar  and  nutmeg  to  taste.     Some  prefer  salt. 
An  excellent  drink  in  diarrhoea,  dysentery,  etc. 

Barley  Water. 
Wash  two  ounces  of  pearl  barley  with  cold  water;  put  the  barley 
in  a  pint  and  a  half  of  fresh  cold  water,  bring  it  to  the  boiling-point, 
and  boil  for  twenty  minutes  in  a  covered  vessel.  Strain,  sweeten  to 
taste,  and  flavor  with  lemon  juice  and  a  little  lemon  peel.  •  (In  some 
cases,  the  lemon  had  better  be  omitted. ) 

Boiled  Flour. 

Tie  up  a  quart  of  flour  in  a  pudding  bag,  tightly ;  put  it  into  a  pot 
of  boiling  water,  and  leave  it  there,  boiling,  for  several  hours  (all  day, 
or  all  night,  will  not  be  too  long).  Then  take  out  the  flour  ball,  and 
di-y  it  near  the  fire.  Pee!  off  and  throw  away  the  thin  outer  poi-tion, 
and  grate  down  the  mass,  with  a  nutmeg-grater,  into  a  powder. 

One  or  two  teaspoonfuls  of  this  may  be  rubbed  into  a  paste  with  a 
small  portion  of  milk,  then  stirred  into  a  pint  of  milk,  which  is  to  be 
scalded,  i.  e.,  just  brought  to  the  boiling-point,  without  being  boiled. 

Useful  in  infantile  cliarrhma,  etc. 

To  Keep  Ice  for  the  Sick. 
Cut  a  piece  of  clean  flannel  about  eight  inches  square.     Put  this 


ALIMENTS,  649 

over  the  top  of  a  glass  tumbler,  pressing  the  flannel  down  to  half  or 
more  of  the  depth  of  the  tumbler.  Then  bind  tiie  Hannel  fast  to  the 
tumbler  with  a  tape  or  cord.  When  the  ice  has  been  i)ut  into  tliis 
ice-cup,  lay  upon  it  another  piece  of  tlanuel,  three  or  four  inches 
square.     It  will  keep  thus  for  hours. 

Oatmeal  Gruel. 
Boil  a  pint  of  water  in  a  saucepan;  when  boiling,  mix  with  it  two 
tablespoonfuls  of  oatmeal  (previously  rubbed  smooth  with  a  little 
cold  water),  half  a  pint  of  milk,  and  a  little  salt.  Let  it  then  simmer 
for  half  an  hour ;  strain  it  through  a  hair-sieve,  sweeten,  and  add  a 
little  uutmeg.     A  few  raisins  may  be  added  before  the  boiling. 

Vegetable  Soup. 
Put  two  potatoes,  one  tomato,  and  a  piece  of  bread,  into  a  quart  of 
water ;  boil  it  down  to  a  pint.     Then  throw  in  a  little  chopped  celery 
or  parsley,  and  salt.     Cover,  and  remove  from  the  fire. 

Bread  and  Butter  Broth. 
Spread  a  shce  of  well-baked  bread  with  good  fresh  butter;  sprinkle 
it  moderately  with   salt  and  black  pepper.     Pour  a  pint  of  boiling 
water  over  it,  cover,  and  let  it  stand  a  few  minutes  before  use. 

Lime-water  and  Milk. 
Take  of  clear  saturated  lime-water  and  fresh  milk,  each  a  wine- 
glassful  ;  mix.     Let  a  tablespoonful  or  less  be  taken  at  once.     This 
will  sometimes  remain  upon  an  irritable  stomach  which  will  retain 
nothing  else. 

Chicken  Broth. 
Clean  half  a  chicken  and  remove  the  skin;  pour  on  it  a  quart  of 
cold  water,  and  salt  to  taste ;  add  a  tablespoonful  of  rice,  and  boil 
slowly  for  two  or  three  hours;  skim  well,  and  add  a  little  parsley. 

Panada. 

Cut  two  slices  of  stale  bread,  without  crust;  toast  them  brown,  cut 
them  up  into  squares  of  about  two  inches,  lay  them  in  a  bowl  and 
sprinkle  with  salt  and  a  little  nutmeg.  Pour  on  a  pint  of  boiling 
water,  and  stand  to  cool. 

Arrowroot. 

Mix  a  tablespoonful,  or  a  tablespoonful  and  a  half,  with  a  little 
cold  w^ater,  till  it  makes  a  paste.  Boil  a  pint  of  water,  stir  in  the 
arrowroot,  and  boil  it  a  few  minutes.  Sweeten  with  white  sugar. 
Brandy,  whisky,  or  wine  may  be  added  if  necessary ;  and  half  or  all 
milk  may  be  used  instead  of  water.  A  little  lemon-  or  orange-peel 
added  before  boiling  will  improve  the  flavor. 

Tapioca. 
Cover  two  tablespoonfuls  of  tapioca  with  a  teacupful  or  more  of 
cold  water,  and  soak  for  two  or  three  hours,  or  over  night.  Put  it 
then  into  a  pint  of  boiling  water,  and  boil  it  until  it  is  clear  and  of 
the  desired  consistence.  Sugar,  nutmeg,  or  wine,  etc.,  may  be  added 
as  required 
55 


650  ALIMENTS. 

Sago  Jelly. 
Mix  well  together  four  tablespoonfuls  of  sago,  tlie  juice  and  rind  of 
one  lemon,  and  a  quart  of  water.     Sweeten  to  taste,  let  it  stand  half 
an  hour,  and  boil  it,  stirring  constantly,  until  clear.      Then  add  a 
wineglassful  of  wine ;  currant  wine  will  do. 

Beef-tea. 
Chop  a  pound  of  lean  beef  into  very  small  pieces,  pour  over  it  a 
pint  or  less  of  cold  water,  cover,  and  let  it  stand  two  hours  by  the 
side  of  the  fire.  Then  put  it  on  the  fire  and  boil  it  for  half  an  hour. 
Remove  the  scum,  skim  off  all  the  oil  drops,  and  salt  to  taste.  Pour 
it  off,  but  do  not  filter  or  strain  it,  unless  through  a  coarse  sieve. 
Oood  'beef-tea  should  have  a  rich  Itroicn  afpearance  when  stirred. 

Frozen  Beef-tea. 
Place  a  convenient  portion  of  beef-tea,  in  a  bottle  or  other  vessel, 
in  an  ice-cream  freezer ;   and  freeze  it  as  cream  would  be  frozen  in 
making  ice-cream.    This  will  be  useful  in  protracted  cholera  infantum, 
etc. 

Farina  Gruel. 
Mix  two  tablespoonfuls  of  farina  with  a  quart  of  water,  and  let  this 
boil  until  it  becomes  thick.     Add  a  pint  of  milk  and  a  little  salt,  and 
then  boil  for  a  quarter  of  an  hour  longer.    Sweeten  according  to  taste. 

Indian  Meal  Gruel. 
Stir  a  tablespoonful  of  Indian  meal  till  it  becomes  smooth  in  half  a 
teacupful  of  cold  water.     Then  mix  it  well  with  a  teacupful  of  boil- 
ing water,  and  boil  it  until  it  is  sufficiently  thickened.    Salt  or  sweeten 
to  taste. 

Bice  Milk. 
Boil  a  tablespoonful  of  rice  for  an  hour  and  a  half  in  a  pint  of  fresh 
milk,  then  rub  it  through  a  fine  sieve.      Add  a  full  teaspoonful  of 
sifted  white  sugar,  and  boil  again  for  two  or  three  minutes. 

Essence  of  Beef. 
Cut  up  a  pound  of  lean  beef  into  small  pieces,  put  it  into  a  pint 
bottle,  without  water,  cork  it  loosely,  and  immerse  the  bottle  to  its 
neck  in  cold  water  in  a  stewpan.     Bring  the  water  to  a  boil,  and  let 
it  boil  for  two  hours.     Then  pour  off  (do  not  filter)  the  essence. 

Extract  of  Baw  Beef. 
Out  up  good  lean  beef  fiery  fine,  and  put  it  with  cold  water  (half 
a  pint  to  a  pound)  in  a  bottle.  Soak  it  for  twelve  hours,  shaking  it 
half  a  dozen  times  or  more  during  that  time.  Then  strain  it  off  with 
pressure  through  a  cloth ;  or,  better,  pour  it  through  a  coarse  sieve. 
Mutton  or  chicken  may  be  treated  in  the  same  way. 

Oatmeal  with  Beef-tea. 
Mix  a  tablespoonful  of  oatmeal  quite  smoothly  with  two  tablespoon- 
fuls of  cold  water.     Add  this  to  a  pint  of  strong  beef-tea,  and  heat 
to  the  boiling-point,  stirring  all  the  time.    Boil  for  five  minutes.    Then 
remove  from  the  fire,  skim,  and  serve  for  use. 


ALIMENTS.  651 

Roast  Oysters. 
Place  a  dozen  fresh  oysters,  in  the  shell  (the  shells  should  he  spon- 
taneously closed  if  good),  iL{)on  a  moderately  strong?  tire,  and  allow 
them  to  remain  there  until  the  shells  hegin  to  open  a  little.  Then 
remove  them,  open  them  at  once,  and  serve  them,  with  a  little  hhick 
pep[)er,  and  salt  if  they  need  it.  This  is  the  method  of  cooking 
oystei's  most  favorable  to  their  digestibility. 

Liehvfs  Broth. 
Chop  half  a  pound  of  beef,  mix  it  well  with  one  drachm  of  table 
salt,  four  dro])S  (ton  would  be  better)  of  muriatic  acid,  and  eighteen 
ounces  <;f  distilled  water.  Macerate  for  an  hour,  and  strain  tlirough 
a  tine  hair  sieve.  Dose,  a  teacupful.  This  contains  the  soluble  con- 
stituents of  the  meat ;  but  not  all  its  nutritive  elements. 

Liehig''s  Food  for  Infants. 
Mix  together  half  an  ounce  of  wheat  flour,  the  same  of  malt  flour, 
seven  and  a  quarter  grains  of  bicarbonate  of  potassium,  and  an  ounce 
of  water.  Add  tive  ounces  of  fresh  milk,  and  put  the  whole  upon  a 
gentle  fire.  When  it  begins  to  thicken,  take  it  from  the  fire,  stir  it 
for  fiv^e  minutes,  heat  and  stir  again  until  it  becomes  quite  fluid ;  finally 
boil  it  for  a  short  time.  Filter  through  a  sieve  to  separate  the  bran;  it 
is  then  ready  for  use.  It  will  keep  for  twenty-fom-  hours.  Its  effect  is 
slightly  aperient. 

Camplin''s  Bran  Loaf  for  Diabetes. 

Take  two  or  three  quarts  of  wheat  bran,  boil  it  in  two  snccessive 
waters  for  ten  minutes,  each  time  straining  it  through  a  sieve,  then 
wash  it  well  with  cold  water  (on  the  sieve),  until  the  water  runs  off 
perfectly  clear;  squeeze  the  bran  in  a  cloth  as  dry  as  you  can,  then 
spread  it  thinly  on  a  dish,  and  place  it  in  a  slow  oven.  If  put  in  at 
night  let  it  remain  until  the  morning,  when,  if  perfectly  dry  and  crisp, 
it  will  be  fit  for  grinding.  The  bran  thus  prepared  must  be  ground  in 
a  fine  raiU,  and  sifted  through  a  wire  sieve  of  sufficient  fineness  to 
require  the  use  of  a  brush  to  pass  it  through ;  that  which  does  not 
pass  at  first  ought  to  be  ground  and  sifted  again,  until  the  whole  is 
soft  and  fine. 

Take  of  this  bran-powder  three  Troy  ounces ;  three  fresh  eggs ;  an 
ounce  and  a  half  of  butter,  and  rather  less  than  half  a  pint  of  milk. 
Mix  the  eggs  with  part  of  the  milk,  and  warm  the  butter  with  the 
other  portion;  then  stir  the  whole  well  together,  adding  a  little  nut- 
meg and  ginger,  or  other  spice.  Just  before  putting  into  the  oven, 
stir  in,  first,  tliirty-five  grains  of  bicarbonate  of  sodium,  and  then 
three  drachms  of  dilute  hydrochloric  acid.  Bake  the  loaf  in  a  basin 
(well  buttered)  for  an  liour  or  rather  more. 

Meigs^  Gelatin  Food  for  Bifants. 
Soak  for  a  short  time  in  cold  water  a  scruple  (a  jjiece  two  inches 
square)  of  prepared  gelatin;  then  boil  it  in  a  half  pint  of  water  ten 
or  fifteen  minutes,  until  it  dissolves.  Stir  into  this  (previously  made 
into  a  paste  with  a  little  cold  water),  at  the  end  of  the  boiling,  a  tea- 
spoonful  of  arrowroot ;  also,  from  three  to  eight  fluidounces  (accord- 


652  ALIMENTS. 

ing  to  the  age  of  the  child)  of  milk ;  and,  lastly,  from  half  a  fluid- 
ounce  to  two  fluidounces  of  cream,  and  a  moderate  amount  of  loaf 
sugar. 

Egg  Broth. 
Boil  (after  it  has  stood,  mixed,  half  an  hour)  two  ounces  of  pearl 
sago  in  half  a  pint  of  water,  until  it  is  smooth  and  thick.  Beat  the 
yolks  of  four  fresh  eggs  with  half  a  pint  of  cream ;  then  mix  with 
the  sago,  and  stir  the  whole  well  with  a  quart  of  boiling  beef-tea, 
just  poured  off.  A  tablespoonf  ul  of  whisky  or,  half  a  glass  of  Sherry 
wine  may  be  added  if  required. 

Wine  Whey. 
Boil  half  a  pint  of  milk,  and,  while  boiling,  add  a  glass  of  Madeira 
or  Sherry  wine.     Separate  the  curd,  by  straining  through  muslin  or 
a  sieve.      Sweeten  the  whey  to  taste,  and  grate  upon  it  a  little  nut- 
meg. 

Egg  and  Wine  or  Brandy. 
Beat  up  a  raw  fresh  egg,  and  stir  with  it  two  tablespoonf uls  of  wine, 
or  one  of  brandy.     Sweeten  or  not,  according  to  taste. 

Caudle. 
Beat  up  a  raw  egg  with  a  wineglassful  of  Sherry,  and  add  to  it 
half  a  pint  of  hot   gruel.     Flavor   with  lemon-peel,    nutmeg,    and 
sugar. 

Milk  Punch. 
Into  a  tumblerful  of  milk  put  one  or  two  tablespoonfuls  of  brandy, 
whisky,  or  Jamaica  rum.     Sweeten,  and  grate  nutmeg  on  top. 

Ferruginous  Chocolate. 
Mix  sixteen  ounces  of  chocolate  with  half  an  ounce  of  carbonate 
of  iron.     Divide  the  mass  into  cakes  of  one  ounce  ejich.     One  may 
be  dissolved  in  half  a  pint  of  hot  milk,  to  be  taken  night  and  morning. 

Koumiss  of  Cow''s  Milk. 
To  a  quart  of  cow's  milk,  add  a  teaspoonful  of  sifted  white  sugar, 
and  a  teaspoonful  of  brewer's  yeast.      Leave  it  to  stand  for  some 
hours  until  fermented;  then  serve  for  use,  or  else  put  away  in  strong 
bottles,  well  corked. 


DISINFECTANTS.  658 


DISINFECTANTS. 

The  best  preventives  of  infection  are  ventilation  and  cleanliness. 

No  agencies  can  be  made  to  take  tbe  place  of  these.  Tbe  following 
are  the  most  available  temporary  aids  in  purification  of  insalubrious 
places : 

For  disinfection  of  privies  :  sulphate  of  iron^  a  pound  dissolved  in 
a  gallon  of  water;  or  the  same  amount  of  chloride  of  lime  may  be 
thoroughly  mixed  in  water.  Common  tar  will  deodorize  a  i)rivy 
(cxce[)t  a  slight  odor  of  its  own)  very  promptly. 

JJurnet's  Li(juid  consists  of  solution  of  chloride  of  zinc,  twenty-five 
gi-ains  in  each  Huidrachm  of  water.  Of  this  a  pint  may  be  put  into  a 
gallon  of  water  for  use. 

For  water-closets,  bed-pans,  etc.,  Labarraque's  solution  of  chlo- 
rinated soda  may  be  employed — a  liuidounce  to  a  quart  of  water ; 
or  perviaiu/anate  of  potassium,''-  ten  gi'ains  to  a  quart  of  water;  or 
carbolic  acid,  twenty  grains  to  the  pint  or  quart.  Chal  tar  possesses 
the  virtues  of  carbolic  acid  in  a  dilute  form.  Fluid  carbolic  acid  may 
be  used  diluted  with  50  to  100  parts  of  water;  or  the  impure  acid,  a 
fluidounce  to  a  gallon  of  water.  Common  petroleum  is  not  a  bad  dis- 
infectant.    Tar  is  a  very  good  one. 

Drinking-water  niay  be  disinfected  by  the  addition  (after  filtra- 
tion) of  enough  permanganate  of  potassium  to  render  it  just  percep- 
tWAy  pink  in  a  strong  hght.  Boiling  will  render  impure  water  much 
safer  to  drink. 

Articles  of  clothing",  contaminated  by  discbarges,  etc.,  from 
patients,  if  very  bad,  should  be  hurned.  Otherwise,  they  should  be 
boiled  thoroughly ;  or,  at  least,  plunged  into  boiling  water.  Solution 
of  permanganate  of  potassium  (an  ounce  to  three  gallons  of  water)  is 
sometimes  used.  Woollens  and  all  clothing  which  cannot  be  washed, 
as  well  as  bedding,  should  be  exposed  for  several  hours  to  a  dry  heat 
of  from  2000  to  250°  Fahrenheit. 

Occupied  rooms  and  houses  may  be  disinfected  (besides  ventila- 
tion) by  diffusing  in  spray  through  the  air  Ledoyen's  liquid  (solution) 
of  nitrate  of  lead,  made  by  dissolving  one  pound  of  litharge  in  seven 
ounces  of  nitric  acid  and  two  gallons  of  water.  Or,  by  placing  in 
shallow  vessels  the  solid  chloride  of  lime  (bleaching  salt).  Or,  sprink- 
ling a  solution  of  carbolic  acid,  1  part  to  100  of  water.  Fresh  white- 
washing is  beneficial  to  the  air  of  a  cellar.  Charcoal  and  qtiicMime 
are  absorbent  (especially  the  former)  of  gases,  and  thus  aid  in  purify- 
ing the  air.  They  may  be  combined,  as  in  what  is  called  "calx  pow- 
der." But  the  best  way  to  disinfect  an  unhealthy  or  suspected  house 
or  room  is,  to  burn  in  it,  with  closed  doors  and  windows  (all  occupants 
of  course  being  first  removed)  sitljihur ;  to  the  amount  of  a  pound 
and  a  half  for  every  thousand  cubic  feet  of  space. 

Hospital  wards  may  be  disinfected  (besides  ventilation  and  cleans- 
ing) by  Ledoyen's  liquid,  chloride  of  lime,  bromine  left  exposed  to  the 
air  in  shallow  vessels,  or  iodine,  heated  moderately.     Emptying  the 

I  The  crude  permanganate  is  much  cheaper  than  the  crystallized,  and  will  answer. 
55* 


654  DISINFECTANTS. 

wards,  however,  and  fumigating  them  for  several  hours  with  burning 

sulphur,  will  be  much  more  effectual. 

Heaps  of  filth,  solid  or  semi-liquid,  may  be  covered  with  charcoal, 

two  or  three  inches  deep,  or  with  dry  earth.       Drains,  ditch.es,  and 

sewers  may  be  disinfected  with  sulphate  of  iron,  coal  tar,  chloride  of 

lime,  etc.     A  pound  of  good  chloride  of  lime  will  suffice  for  a  thousand 

gallons  of  running  sewage. 

CMoralum  and  Salicylic  acid  are  good  antiseptics  and  disinfectants. 
On  the  subject  of  ozone  as  a  disinfectant,  the  reader  is  referred  to 

works  on  chemistry  and  hygiene. 


INDEX  OF   FORMULA. 


Agile.    See  Intermittent  Fever. 
Alimentary  preparation,  page  648. 
Amenorrhoea,  F.  201.  202, 271,  275,  279,  297. 
Anscraia,  F.  23,  30.  33,  56.  71,  267,  2G9,  270, 

271,  295.  296,  300,  301.  302. 
Angina  Pectoris,  F.  47,  48, 49,  278,  299,  300, 

301,  304,  308.  320. 
Arsenical  Poisoning,  F.  220.  (See  p.  482.) 
Asthma,  F.  18,  19,  20,  98, 153,  278,  314,  315, 

316,  317,  320. 

Baldness,  premature,  F.  185, 186. 
Benzoate  of  Sodium,  F.  283. 
Biliousness,  F.  221,  222,  241,  290,  301. 
Boracic  Acid,  F.  343. 
Brain,  congestion  or  inflammation  of,  F. 

151.  221,  222,  311,  313,  323. 
Bronchitis,  F.  1.  4, 13, 14, 15, 16. 17,  20,  239, 

240,  314,  315,  .316,  317,  318,  319,  320. 
Bunions,  F.  260,  261. 

Carbolic  Add,  F.  256,  260,  261,  331,  332, 341, 

342,  361,  371. 
Chloral  Hydrate,  F.  257,  304,  308,  319,  353, 

360,  370. 
Chlorosis,  F.  213,  267,  269,  271,  276,  296, 

300,  301. 
Cholera,  F.  91,  92,  245,  266.  p.  410,  note. 
Cholera  Infantum,  F.  107,  108,  109,  110, 

265,  327,  328. 
Cholera  Morbus,  F.  99. 289.  (See  Vomiting.) 
Chorea,  F.  22,  23,  32,  33,  34,  306. 
Colic.  F.  74,  78,  79,  86,  87,  89,  90,  91,  93,  94, 

96, 100. 
Constipation,  F.  75,  76,  77, 82,  83,  84,  85,  95, 

141,  221,  262,  275,  279.  280,  324,  325. 
Consumption.    See  Phthisis. 
Cough,  F.  13,  14,  15,  16,  17,  19,  20.  35,  36, 

240,  311.  314,  315,  316,  317,  318,  319,  320. 
Croup,  F.  5,  24,  25,  26,  331,  333. 

Delirium  Tremens,  F.  144,  145,  304,  305, 

308. 
Diarrhoea,  F.  101,  102,  103,  104,  105,  106, 

110,  265,  326,  327,  328. 
Dietetic  formula,  page  648. 
Diphtheria,  F.  54,  55,  56, 1.56, 157, 158,  213, 

225,  282.  283,  331,  332,  3.33,  334. 
Dropsy,  F.  8,  10,  11, 12,  38,  39,  40,  268,  277, 

313,  323. 
Dysentery,  F.  97,  111,  112, 113, 114, 115, 116, 

117. 
DvJ-menorrhoea,  F.  124, 125,  203   303,  304, 

305,  306,  376. 


Dyspepsia,  F.  34.  71,  72,  73,  74,  75,  76  274. 
275,  290,  292,  293,  295,  296. 

Earache,  F.  133. 
Epilepsy,  F.  254. 
Erysipelas,  F.  5, 180, 184. 

Fever,  F.  7, 149, 150, 165, 166,  227,  310,  311, 
312. 

Gangrene  of  Lung,  F.  2,  3, 152. 
Gastritis,  chronic,  F.  62,  63,  64. 
Glanders,  F.  1.52. 
Gonorrhcea,  F.  171, 172,  173,  174,  175,  205, 

330  377 
Gout!  F.  37.  45,  47,  48,  49,  230. 
Gravel,  F.  122,  123,  124,  125,  126. 

Haematemesis,  F.  80.  81. 
Haemoptysis.    See  Spitting  Blood. 
Hemorrhages,  F.  146, 147.  .321.  (See  p.  326.) 
Hoarseness,  F.  5, 13,  14,  239. 
Hooping-cough,  F.  19,  20,  98, 153, 154, 155, 

305,  306.  315,  320. 
Hypertrophy  of  the  Heart,  F.  41,  42,  44. 
Hysteria,  F.  22.  23, 134,  142,  143,  267,  270, 

271,  272,  300,  301,  305. 

Influenza,  F.  2,  13, 14, 15,  225,  309,  310,  311, 

312. 
Insomnia,  F.  22. 143, 144, 145,  256, 303,  304, 

305,  306,  308. 
Intermittent  Fever,  F.  2, 159, 160, 161, 162, 

226,  270. 
Iodoform,  F.  276,  342,  348,  349,  363, 367,  368, 

374. 

Jaundice,  F.  21,  221,  222,  293,  294,  301,  324. 

Laryngitis,  F.  1,  4.  5,  310.  311,  312. 
Leucocythajmia,  F.  213,  269,  270,  271,  276, 

302. 
Leucorrhoea,  F.  204,  205,  328,  376. 
Lice,  F.  210,  211,  212,  361. 

Neuralgia,  F.  27,  28,  29, 162,  216,  217,  219, 
271,  272.  276,  298,  304,  305,  306,  308,  350, 
a53,  355. 

Neurasthenia,  270,  271,  272,  273,  295,  296, 
298,  300,  301,  302. 

Ophthalmia.  F.  88, 128,  129,  130,  131,  335, 

336,  337. 
Ozcena,  F.  205,  329,  340,  341,342,  343,  344. 

655 


656 


INDEX    OF    FORMULA. 


Palpitation,  F.  66,  72,  90,  216,  292,  305. 
Paralysis,  F.  34, 137, 138, 139. 
Pericarditis,  Endocarditis,  F.  4,  6,  7,  8,  9, 

10,  310,  311,  312. 
Periostitis,  F.  88, 180,  349,  351, 352,  363,  365. 
Peritonitis,  F.  6,  7,  8,  9,  111,  113. 
Pernicious  Fever,  F,  163,  164. 
Phosphorus,  F.  246,  252,  272.  273,  298. 
Phthisis,  F.  30.  31,  32,  33,  35,  36, 140,  267, 

276,  314,  315,  317,  318. 
Piles,  F.  88, 118,  119,  120,  121,  124,  125,  347, 

367,  376. 
Pleurisy,  F.  1,  4,  6,  7,  8,  9, 10,  11,  278.  310, 

311  312  313. 
Pleurodynia,'  F.  27,  28,  29,  138,  139,  277, 

303,  350,  353.  354. 
Pneumonia,  F.  1,  2,  3,  4,  6,  7,  8,  310,  311, 

312,  316. 
Poisons,  page  482. 
Pyaemia,  F.  2,  3, 132. 

Remittent  Fever,  F.  2,  7.  226,  310. 
Rheumatism,  F.  37,  45,  46,  61,  79, 138, 139, 
167, 168, 230, 243, 262.  (See  Salicylic  Acid.) 

Salicylic  Acid,  F.  262,  284,  285, 286, 287, 288, 

333,  334. 
Scarlet  Fever,  F.  7,  26,  149,  150,  151,  224, 

255.  309,  310,  311,  312,  313. 
Scrofula,  F.  30,  31,  32,  33, 176,  276. 


Sick  Headache,  F.  66,  74,  290,  292. 

Skin,  Diseases  of,  F.  148, 177,  178, 179, 180, 
181,  182,  183,  184,  187,  188,  189,  190,  191, 
192,  193,  194,  195,  196,  197,  198,  199,  200, 
236,  237,  238,  S46,  349,  351,  352,  356,  357, 
358,  359,  360,  361,  363,  364,  365,  366,  367, 
369,  372. 

Sore  Mouth,  F.  50,  61,  52,  53,  54,  57,  58,  59. 

Sore  Nipple,  F.  373,  374. 

Sore  Throat,  F.  5,  52,  54.  59,  332,  339. 

Spermatorrhoea,  F.  22,  30,  33, 162,  807. 

Spitting  of  Blood,  F.  80,  81,  146, 147,  321. 
(See  p.  327.) 

Sprains,  F.  138, 139,  350,  369. 

Syphilis,  F.  61,  169,  170,  215,  231,  232,  269, 
276,  294,  337,  348,  349. 

Tetanus,  F.  257.    (See  p.  313.) 

Tonsillitis,  F.  5,  60,  228,  310,  311,  312. 

Tumors,  F.  234,  242,  363. 

Typhlitis,  F.  87,  351,  352. 

Tvphoid  Fever,  F.  2,  7, 147, 150, 165,  309. 

Typhus  Fever,  2,  7, 150, 165,  309. 

Ulcer  of  Stomach,  F.  62,  63,  64,  80,  SI. 

Vomiting,  F.  63,  64,  65,  66,  67,  68,  69,  70, 
289,  290,  291,  292. 

Worms,  F.  206,  207,  208,  209,  322. 


(For  Metrical  Presckiptions,  see  pa^e  647.) 


GENERAL   INDEX. 


ABDOMINAL  diseases,  physical  diag- 
nosis of,  115. 
Abdominal  dropsy.  406. 

traction,  28(),  .'iuo. 
Abscess  of  the  brain,  342. 

liver,  303. 

lung,  206. 

retro-pharyngeal,  262. 
Acarns  foUiculoriim.  549,  585. 
Acetate  of  animoniimi,  F.'  7. 

lead  and  opium  pills,  F.  114. 

lead  pills,  F.  41. 

morpnia  for  hypodermic  use,  185. 

potassium,  F.  8. 
Acetonsemia,  31. 
Acidity  of  perspiration,  93. 

urine.  179. 
Aclnesia,  95. 

Aconite  147;  F.  310,  360. 

embrocation,  F.  27. 
Acrodynia,  433. 
Acute  phthisis,  231. 

softening  of  stomach,  203. 

yellow  atrophy  of  liver,  307. 
Addison's  disease,  533. 
Ad6nie  of  Trousseau,  525. 
j?r;gophony,  107. 
Aflections  of  alimentary  system,  257. 

brain  and  nervous  system,  335. 

heart  and  aorta,  239. 

kidneys  and  bladder,  315. 

liver.  301. 

respiratory  system,  194. 

skin,  .036. 

spleen,  314. 
Agoraphobia,  63. 
Ague.  433. 

cake,  314. 
Air,  impure,  promotive  of  phthisis,  232. 
Alarm,  at  night,  in  children,  378. 
Albuminuria,  83,  317. 
Alcohol  injection  in  neuralgia,  394. 

in  treatment  of  debility,  158. 

in  urine,  79. 
Alimertary  preparations,  648. 
Alimentation,  hvpodermic,  187. 

rectal,  265,  267. 
Alison.  22. 

Alkalies  in  gout  and  rheumatism,  166. 
Alkalinitv  of  urine,  80. 
Aloes,  F.  279. 

and  iron,  F.  202. 

pills,  F.  201. 

rhubarb  and  belladonna,  F.  85. 
Alopecia,  547. 
Alphos,  543. 
Alterative  treatment,  109. 


Alum,  brandy,  and  water,  F.  59. 

eye-water,  F.  129. 

lotion,  F.  204. 
Amaurosis,  340. 
Amblyopia,  96. 
Amenorrhcea,  562. 
Ametropia,  593. 
Ammona^mia,  315. 
Ammonia  mixture,  F.  3. 

rliubarb  and  paregoric,  F.  109. 

soda  and  morphia,  F.  67. 
Ammoniated  urine,  81,  315. 
Ammonio-ferric  alum,  F.  80. 
Amphoric  sounds,  102, 109. 
Amyl  nitrite,  27,  183,  250. 
Amyloid  kidnev,  331. 

liver,  311. 
Analeptic  treatment,  157. 
Analysis  of  urine,  76. 
Anaemia,  31,  518. 

progressive  perniciou.s,  ,519. 
Anaesthesia,  95,  284,  556. 

for  diagnosis,  219,  284. 
Ansesthetics,  179. 
Anaphrodisiac  mixture,  F.  307. 
Anasarca,  405. 
Aneurism  of  aorta,  253. 

abdominal,  255. 

miliary  of  Charcot,  319. 

thoracic,  253. 
Angeioleueitis.  530. 
Angina  pectoris,  250. 
Animism,  16. 
Ankle-clonus,  358,  368. 
Anodyne  remedies,  163. 
Anorexia,  68. 
Anoxamia,  31. 
Anthelmintics,  578  ct  seq. 
Anthrax,  532. 
Anthroijophobia,  63. 
Antidotal  treatment,  164. 
Antidote  for  arsenic,  F.  220. 
Anti-emetics,  265. 
Antilitliics,  165. 
Antimony  as  a  remedy,  146. 
Antiphlogistic  treatment.  141. 
Antipruriginous  lotion,  F.  191. 
Antipsorics,  165. 
Antipyretic  treatment,  152. 
Antiscorbutics,  166.  ' 
Antiseptic  remedies,  107. 
Antisyphilitic  treatment,  166. 
Anus,  fissure  of,  300. 

prolapsus  of,  301. 
Aorta,  aneurism  of,  253. 
Aortic  stenosis,  256. 
Aphasia,  384. 
Aphonia,  218. 


1  F.,  Formula;  p.  601  ct  scq. 
2R 


657 


658 


GENERAL    INDEX, 


Aphthse,  258. 

Apnoea,  death  by,  66. 

Apoplectic  syncope,  248. 

Apoplexy,  348. 

Apomorphia,  186,  222,  375. 

Apparatus  for  examination  of  urine,  91. 

Appetite  in  disease,  68. 

Arachnitis,  335. 

spinal,  353. 
Arcus  senilis,  96. 
Aretseus,  14, 18. 
Argyll-Robertson  pupil,  369. 
Army  itch,  558. 

Aromatics,  etc.,  for  colic,  F.  89. 
Arrowroot,  649. 
Arsenic  in  anaemia,  518. 
Arsenical  poisoning,  586. 
Arterio-capillary  fibrosis,  321. 
Arthritis,  502. 
Artificial  respiration,  590. 
Asarum  for  ascarides,  580. 
Ascarides,  580. 
Ascites,  406. 
Asclepiades,  15. 
Asphyxia,  590. 
Aspirator,  pneumatic,  133. 
Assafoetida  and  expectorants,  F.  153. 

mixture,  F.  98. 

pills,  F.  143. 
Asthenia,  death  by,  66. 
Asthenopia,  594. 
Asthma,  210. 

A.stigmatism,  593,  596,  599. 
Astringent  and  sedative  lotion,  F.  195. 

powder,  F.  189. 
Ataxiee,  193. 

Ataxie  locomotrice  progressive,  368. 
Atelectasis  pulmonum,  207. 
Atheroma,  349. 
Athetosis,  370. 
Atomization,  181. 
Atrophy,  45. 

of  liver,  acute  yellow,  307. 
Atropia,  F.  336,  347. 

for  night-sweats,  236. 

solution  for  the  eye,  F.  131. 
Auscultation,  103. 
Autopsic  inspection,  134. 
Aveling,  apparatus  for  transfusion,  188. 

BABINGTON,  the  first  laryngoscope,  119. 
Bacillus  malariee,  436. 
Bacon,  15. 

Balancive  remedies,  139. 
Baldness,  547. 
Barbadoes  leg,  548. 
Barthez,  16. 
Basedow's  disease,  250. 
Basham's  mixture,  F.  268. 
Battey's  operation,  569. 
Beef  essence.  650. 

raw,  extract,  650. 

tea,  650. 
Belladonna,  F.  359,  360,  377. 

mixture,  F.  154. 

ointment,  F.  120. 

suppositories,  F.  125. 
Bell's  disease,  399. 

Benzoate  of  sodium,  169,  235,  499,  F.  283. 
Benzoic  acid,  F.  126. 

and  soda,  F.  123. 

for  albuminuria,  322. 
Bergson's  steam-inhaler,  181. 
Beriberi,  ,522. 

in  Japan,  522. 


Bernard,  experiments  of,  140. 

on  liver-sugar,  327. 
Bibron's  antidote,  589. 
Bichat,  16. 
Bigelow,  18,  23. 
Bile,  agents  increasing,  in  dogs,  302. 

in  urine,  tests  for,  78. 
Bilharzia,  579. 
Bilious  dysentery,  296. 

fever,  439. 
Billing  on  support  and  depletion,  156. 
Bismuth,  pepsin,  and  strychnia,  F.  292. 
Bites  of  serpents,  589. 
Bitters  in  debility,  157. 
Bladder,  inflammation  of,  333. 
Bland's  pills,  F.  271. 
Bleeding  from  the  nose,  401. 
Blood,  desiccated,  162. 

in  disease,  70. 
Blood-corpuscles,  counting,  71,, 

in  urine,  83. 
Bloodletting,  142. 

authorities  upon,  143. 
Blood-root,  F.  316. 
Blood,  spitting  of,  402. 

vomiting  of,  403. 
Blowing  respiration,  104. 108. 
Blue  mass  and  ipecac,  F.  111. 

ipecac,  and  camphor,  F.  112. 
Blue  vitriol  lotion,  F.  193. 
Boerhaave,  16. 

Boracic  acid,  344,  347,  F.  335,  343. 
Borax,  myrrh,  etc.,  F.  52. 
Borelli,  16, 18. 
Bothriocephalus,  578. 
Bottger's  test  for  sugar,  86. 
Bouchardat's  bread  for  diabetics,  82S, 
Bougies,  medicated,  512. 
Bowels,  hemorrhage  from,  404. 

inflammation  of,  273. 

obstruction  of,  284. 
Brain,  abscess  of,  342. 

ejections  of,  335. 

exhaustion,  340. 

inflammation  of,  335. 

softening  of,  342. 
Bran  loaf,  Camplin's,  651. 
Bread  and  butter  broth,  649. 
Breakbone  fever,  432. 
Breath  in  fever,  26. 

temperature  of,  74. 
Bright's  disease,  317. 
Bromide  of  ammonium,  374.  F.  134. 

of  potassium,  163,  F.  22,  254,  304,  306, 
308. 

of  sodium,  163. 
Bromine  in  epilepsy,  374. 

for  rhus  poisoning,  561. 
Bromo-camphor,  163. 
Bronchial  dilatation,  214. 

sounds,  105, 107,  108. 
Bronchiectasis,  214. 
Bronchitis,  208. 
Bronchocele,  534. 
Bronchophony,  106, 107, 
Broussais,  17. 
Brown,  17. 
Brown-Sgquard,  17. 
Bucnemia  tropica,  548. 
Buhl,  resorption  theory  of  tubercle,  40, 
Bulbo-nuclear  sclerosis,  358. 
Bulging  of  the  chest,  100,  253. 
Bulimia,  68. 
Bullse,  .541. 
Burns  and  scalds,  562. 


GENEliAL    INDEX. 


659 


CACHEXIA,  32. 
Cujiipiit  oil,  lf)7,  282. 
Calabur  bciui  in  chorea,  383. 

in  k'tunus,  oSO. 
Calculu.s,  '.tl.  :i2l. 
California,  clinuite  of.  238. 
Ciilnuitivu  rL'uicilie^,  1G3. 
Calomel  powders,  F.  09. 

and  eamphor  ointment,  F.  237. 

and  nitre,  P.  25. 

ipecae.  and  nitre,  F.  0. 

and  opium  pills,  F.  80. 

opium,  and  tartar  emetic,  F.  9. 

quinine,  camplior,  and  opium,  F.  164. 

soda,  and  ginger,  F.  107. 
Camman's  double  -stethoscope,  103. 
Camp  fever,  4tJl. 
Camphor  mixture,  F.  103. 

ipecac,  and  opium,  F.  113. 

lavender,  paregoric,  and  ginger,  F. 
203. 
Camplin'.s  bran  loaf,  651. 
Cancer,  57. 

of  kidney,  330. 

of  liver,  312. 

of  stomach,  267. 
Cancrum  oris,  259. 

Cantharides  and  castor  oil  pomade,  F. 
18G. 

and  iron,  F.  2i)7. 
Capillary  circulation  in  disease,  70. 
Capsicum  pilLs,  F.  163. 
Cap.sule  of  Glisson,  inflammation  of,  303. 
Carbolic  acid  as  antizymotic,  168. 

doses  of,  note,  418,  F.  2.55,  260,  261. 

formulae  containing,  F.  331,  332,  341, 
358.  362,  363,  372. 

and  glycerin,  F.  212. 

inhalation  of,  183. 
Carbonate  of  ammonium  in  urine,  81. 

of  potassium  and  nitre,  F.  37. 

ointment,  F.  200. 
Carbuncle,  532. 

Cardamom  and  potassa  mixture,  F.  66. 
Cardiac  exhaustion,  253. 
Cardialgia,  268,  271. 

Carey,  Matthew,  yellow  fever  of  1793,  453. 
Caries  of  the  spine,  516. 
Carminative  mixture,  F.  78. 

anodvne,  F.  90. 

for  infants,  F.  94. 
Carotid,  ligature  of,  for  neuralgia,  395. 
Castor  oil  and  laudanum,  F.  97. 

and  spiced  syrup  of  rhubarb,  F.  96. 
Catalepsy,  375. 
Catalysis  in  di.sease,  29. 
Catarrh,  chronic  nasal,  215. 

epidemic,  432. 

summer,  213. 
Catarrhal  croup,  221. 
Catechu  and  paregoric,  F.  105. 
Cautery,  actvial,  149. 
Cavernous  respiration,  106. 
Cellular  pathology,  19,  48. 
Celsus,  15. 
Cephalalgia,  97,  395. 
Cerate  of  carbonate  of  lead,  F.  88. 
Cerebellar  absce.ss.  312. 
Cerebral  and  spinal  sclerosis,  355, 
Cerebritis,  3:j5. 
Cerebro-spinal  fever,  457. 

meningitis.  457. 
Cerium  oxalate.  210. 
Chalk  mixture,  F.  102. 
Chancroid,  507. 


Chapman,  N.,  pathology  of,  17. 

on  phthisis,  228. 
Ohaulnioogra  oil,  545. 
(;heloi(i,  553. 
(Ihemiater,  16. 

Chemical  analysis  of  urine,  76,  91. 
Cliiun  turiieiitine,  268. 
Chicken  broth,  649. 

pox,  414. 
Chigoe.  585. 
Chilblain,  561. 
Child-bed  fever,  476. 
Children,  consumption  in,  238. 
Chills  and  fever.  V.i^i. 
Chloasma,  547,  560. 
Chloral,  depression  from,  163. 

formulae  containing,  F.  304,  308,  319, 
332,  353,  355,  361,  371.         • 

hydrate  of,  163,  F.  256. 

in  urine,  87. 
Chlorate  of  potassium,  F.  54,  156,  282. 

with  iron,  F.  157. 
Chloride  of  sodium  in  urine,  91. 

of  iron,  F.  57. 
Chlorides  in  prescription.  F.  269. 
Chlorinated  soda  and  glycerin,  F.  57. 
Chlorodyne,  F.  217. 
Chloroform,  inhalation  of,  179. 

and  camphor,  F.  100. 

Hottmann's  anodyne,  etc.,  F.  49. 

liniment,  F.  28. 

mixture,  F.  91. 

paregoric,  Nos.  1  and  2,  F.  92,  93. 
Chlorosis.  521. 
Choked  disk,  123,  337. 
Cholaemia,  30. 
Cholecystotomy,  314. 
CholeiTi,  478. 

infantum,  291. 

morbus,  287. 

winter,  288. 
Cholestera^mia,  30. 
Cholesterin,  92,  281. 
Choluria,  79. 
Chorea,  382. 
Choreic  spasm,  62. 
Chronic  diarrhoea.  291. 

ga.stritis,  264. 

inflammation,  54. 

nasal  catarrh,  215. 

pleurisy,  203. 
Chrysophanic  acid,  543. 
Cider  mixture,  F.  40. 
Cinchonated  syrup  of  iron,  F.  219. 
Cinchonia  in  intermittent,  437. 
Cinchonization,  165. 
Circulation,  symptoms  affecting,  69. 
Circulatory  organs,  affections  of,  239. 
Cirrhosis  of  liver,  309. 

of  lung,  200. 
Citrate  of  iron,  F.  23. 

magnesium  solution,  F.  223. 
Classification  of  diseases,  192. 

of  remedies,  139. 
Clavus,  548. 

Clergyman's  sore  throat,  219. 
Climates  for  the  consumptive,  237. 
Clitoridectomy,  375. 
Clonic  spasm,  62. 
Club-foot,  371. 
Coarse  crepitant  rale,  109. 
Coca,  164. 
Cocculus  Indicus,  F.  211. 

in  epilepsy,  375. 
Cod-liver  pil,  157,  F.  30, 104. 


660 


GENERAL    INDEX, 


Cod-liver  oil  in  phthisis,  233. 

and  glycerin,  F.  31. 

iron  and  quinine.  F.  32. 
Colchicum  in  gout,  1G6. 

and  alkalies,  F.  46. 

and  ipecacuanha,  F.  182. 

and  magnesia,  F.  45. 
Cold  applications,  141. 

baths  in  fever,  152,  471. 

cream  with  zinc,  F.  178. 
Colic,  277. 

prevention  of,  283. 

remedies  for,  283. 
Collapse  of  lungs,  207. 
Collodion  styptic,  F.  250,  251. 
Colloid  degeneration  of  liver,  .311. 
Collyrium  of  nitrate  of  silver,  F.  130. 
Color  bli^idness,  600. 

of  the  skin  in  di.sease,  74. 
Colorado  for  asthmatics,  213. 
Coloring  matters  in  urine,  77. 
Colotomy,  286. 
Coma,  97'. 

death  by,  66. 
Compound  cathartic  pills,  F.  222. 

rhubarb  pills,  F.  221. 

spirits  of  juniper,  F.  11. 
Conclusions,  general,  in  therapeutics,191. 
(Condylomata,  548. 
Congestion  of  kidneys,  315. 

of  the  liver,  301. 
Congestive  fever,  445. 
Conjunctivitis.  343. 
Constipation,  272. 
Constructive  antidotes,  165. 
Con.sumption,  227. 
Contro-stimulant  treatment,  146. 
Convulsions,  379. 
Copaiba,  F.  330. 

mixture,  F.  17, 174. 
Cophosis,  347. 

Copper,  protection  against  cholera,  490. 
Cord,  spinal,  iniiammation  of,  353. 

softening  of,  353. 
Corneitis,  344. 
Corns,  548. 
Corrigan's  pulse,  70. 
Corrosive  sublimate  lotion,  F.  194,  210. 
Coto,  290. 
Cough,  73. 
Countenance,  expression  of,  in  disease, 

97. 
Counter-irritation,  149. 
Coup  de  soleil,  376. 
Cow-pox,  411. 
Coxalgia,  517. 
Oackle,  107. 
Cramp  of  stomach,  282. 
Cream  of  tartar  and  dandelion,  F.  39. 
Creasote  pills,  F.  81. 

and  glycerin,  F.  58, 158. 

soda  and  morphia,  F.  68. 
Crepitant  rale,  107. 
Cretinism,  534. 
Croton  oil,  F.  127. 

chloral  hydrate,  137. 
Croup,  220. 
Croupal  catarrh,  221. 
Crusta  lactea,  539. 
Cruveilhier's  palsy,  366. 
Cubebs  mixture,  F.  175. 
Cullen,  18, 192. 

Cunisset's  test  for  bile,  78.  4 

Cupping,  145. 
Curara  in  hydrophobia,  388. 


Currie,  cold  affusion  in  fever,  152. 
Cutaneous  affections,  536. 
Cyanide  of  potassium,  F.  317. 
Cyanosis,  70. 
Cylindrot83nium,  485. 
Cystine,  82. 
Cystitis,  833. 
Cysts  of  liver,  313. 
of  kidneys,  317. 

DAMIANA,  F.  276. 
Dance,  St.  Vitus's,  382. 
Da  Vinci,  13. 
Deafness,  347. 
Death  in  heart  disease,  249. 

modes  of,  66. 
Decubitus  in  disease,  93. 
Degeneration,  55. 

fatty,  of  the  heart,  248. 

treatment  of,  171. 
De  Lebo,  18. 
Delirium,  97. 

tremens,  395. 
Dementia,  308. 

paralytic,  367. 
Demme,  cranium-holder,  134. 
Demodex  folliculorum,  549,  585. 
Dengue,  432. 
Depression,  156. 

of  the  chest  locally,  100. 
Diabetes  insipidus,  325. 

mellitus,  326. 
Diabetic  sugar,  tests  for,  84. 
Diagnosis,  physical,  98. 
Diaphoretics  in  fever,  157. 
Diarrhoea,  289. 
Diatheses,  192,  497. 
Dicrotous  pulse,  70. 
Diet,  In  disease,  146. 
Dietetic  formulse,  648. 
Dieulafoy's  aspirator,  133. 
Digestibility  of  foods,  272. 
Digestive  organs,  affections  of,  257. 

system, symptoms  connected  with,67. 
Digitalis,  F.  42,  43. 

in  heart-disease,  247. 

squills,  etc.,  F.  38. 

with  iron,  F.  299. 
Dilatation,  bronchial,  214. 

of  the  heart,  246. 

of  OS  uteri,  446. 

of  Stomach,  264. 
Dimensions  of  the  chest,  99. 
Diphtheria,  424. 
Diphtheritic  paralysis,  364. 
Diplopia,  96. 
Dipsomania,  397. 
Disease,  definition  of,  25. 
Diseases,  classification  of,  192. 
Disinfectants,  653. 
Disinfection  after  autopsies,  137. 
Displacement  of  organs  from  effusion, 

etc.,  109. 
Dissecting  wounds,  530. 
Distomata,  579. 
Diuresis,  75. 
Diuretic  pills,  F.  313. 
Dochmius  duodenalis,  580. 
Dogmatic  medicine,  14. 
Donovan's  solution,  F.  170. 
Doses  for  inhalation,  183. 

in  hypodermic  meditation,  185. 

metrical,  646. 
Dracunculus,  584. 
Drainage  in  pleuritic  effusion,  205. 


GENERAL    INDEX. 


661 


Dropsies,  405. 

Dropsy  of  the  head,  SIO. 

Drowning,  o'JO. 

Dry  craclvle,  107. 

Dry  sounds  on  auscultation,  104.   ' 

Drysdale's  t;ranular  cell,  -107. 

Duehenne's  di.sease,  3(i7. 

Dumbness,  feigncil,  2V\ 

Dysentery,  2!M. 

scorbutic,  506. 
Dysmenorrhcea,  5C4. 
Dyspepsia,  2(>8. 
Dysphagia,  68. 
Dysphonia.  219. 
Dyspntea,  73. 
Dysuria,  33i. 

EARACHE,  ai6. 
Ear,  inflammation  of,  tUO. 
Ears,  sounds  in,  96. 
Echinococcus,  577. 
Echo,  metallic,  109. 
Eclampsia  nutans,  379. 
Eclecticism,  15. 
Economic  remedies,  139. 
Ecthyma,  512. 
Eczema,  538. 

Effervescence  in  urine,  81. 
Effervescing  draught,  F.65. 

fever  powders,  F.  227. 
Electricity  as  a  remedy,  171. 
Electropuncture,  17-1. 256. 
Elephantiasis  Arabum,  548. 

Grrecorum,  553. 
Elimiuative  remedies,  139. 
Emaciation.  74. 
Embolism,  528. 

multiple,  243,  528. 
.Smmetropia,  593. 
Emphysema  of  lung,  207. 
Empirical  medicine,  14,  20-23. 
Emprosthotonos,  386. 
Empyema,  203. 

vocal  resonance  in,  108,  201. 
Encephalitis,  335. 
Endocarditis,  242. 

ulcerative,  243. 
Enema  of  castor  oil,  etc.,  F.  141. 

laudanum  and  starch,  F.  115. 

sulphate  of  zinc  and  laudanum,  F. 
116. 
Enteric  fever,  464. 
Enteritis,  273. 
Entozoa,  576. 
Enuresis,  335. 
Ephelis,  547. 
Epidemic  and  sporadic  inflammations 

contrasted,  151, 
Epilepsy,  372. 
Epistaxis,  401. 
Epi.synthetism,  14. 
Epizoa,  585. 
Equinia,  431. 
Ergophobia,  63, 
Ergot,  as  an  antiphlogistic,  147. 

hypodermically,  187. 

in  suppository," F.  276. 
Eruptions,  medicinal,  536. 
Ervsipelas,  474. 
Erythema,  536. 
Erythromelalgia,  55. 
Ether  spray  to  spine  in  chorea,  383. 

in  tetanus,  386. 
Eucalyptus  globulus,  in  ague,  43S. 
Exanthemata,  536. 

56 


Excito-secretory  action,  62. 
Exclusivism,  175. 
Exhaustion,  157. 

of  the  hc'urt,  253. 
Ex-oi)htlialmic  goitre,  2.50. 
E.xpansion  of  the  chest,  99. 
Expectant  medicine,  23. 
Expectoration,  74. 
Exi)iratory  murmur,  105. 
Explo.sive  pharmacal  compounds,  643. 
E.xpression  of  tlie  face  in  disease,  97. 
Extra-cardiac  soiiffles,  115. 
Exudation,  50. 
Eyes,  changes  of  in  disease,  95. 

inflammation  of,  343. 
Eyesight,  e.xamiuatiou  and  correction. 
592. 

FACIAL  palsy,  360. 
Facies  Hippocratica,  97. 
Famine  fever,  455. 
Faradization,  171. 
Fatty  degeneration  of  the  heart,  248. 

embolism,  528 

liver,  310. 

urine,  91. 
Favus,  558. 

Fawn-colored  deposits  in  urine,  81. 
Febrifuge  treatment,  151. 
Feeble  respiration,  108. 
Feigned  dumbness,  219. 
Felon,  531. 

Ferguson's  .speculum,  lis. 
Fermentation  test  for  sugar,  86. 
Ferrier,  63,  361. 
Fever,  cerebro-spinal,  457. 

cot,  Kibbee's,  141. 

flood,  of  Japan,  475. 

intermittent,  433. 

malarial,  433. 

pathology  of,  26. 

pernicious,  445. 

puerperal,  476. 

relapsing,  455. 

remittent,  439. 

scarlet,  415. 

treatment  of,  151. 

typhoid,  464. 

typho-malarial,  448. 

typhus,  61. 

yellow,  449. 
Filaria  medinensis,  584. 

newly  discovered,  585. 

producing  elephantiasis,  548. 

sanguinis  hominis,  584. 
Fissure  of  anus,  300. 
Fleas,  585. 

Flood  fever,  of  Japan,  475. 
Fluctuation,  115. 

Fluid  extract  of  hyoscyamus,  F.  155. 
Fluorescence  in  human  blood,  165. 
Fluoric  acid  in  goitre.  534. 
Follicular  pharyngitis,  219,  261. 

stomatitis,  258. 
Food,  digestibility  of  different   kinds, 
272. 

for  the  sick,  648. 
Forbes,  Sir  John,  18,  23. 
Formulee,  601. 
Foulis,  ovarian  cells,  407. 
Friction-sounds,  loS. 

sounds  of  the  heart,  115. 
Friederickshall  water,  522. 
Frostbite,  561. 
Fungoid  neoplasm,  551. 


662 


GENERAL    INDEX. 


GALEF,  15. 
Galvanism  as  a  remedy,  171. 
Gall-bladder,  aff'ectious  of,  314. 

puncture  of,  314. 
Gallic  acid,  F.  146,  321. 
Galloping  consumption,  231. 
Gall-stones,  92,  278,  280. 

impaction  of,  278. 
Galls,  aromatic  syrup  of,  F.  321. 
Ganglia  in  Bright's  disease,  321, 
Ganglio-therapy,  140. 
Gangrsena  oris,  259. 
Gangrene  of  lung,  206. 
Gastric  remittent,  264. 
Gastritis,  263. 

subacute,  of  children,  264. 
Gastrodynia,  271. 
Gastro-hepatic  catarrh,  263. 
Gastrotomy,  286. 
General  paralysis  of  insane,  367. 

pathology,  25. 

therapeutics,  138. 

vital  condition,  98. 
Gentian  and  rhubarb  pills,  F.  73. 

and  rhubarb,  tincture,  F.  72. 

rhubarb  and  blue  mass,  F.  74. 
Gheel,  400. 
Giant  cells,  42. 
Gin  liver,  309. 
Glanders,  431. 
Glaucoma,  124. 
Glioma,  343. 
Glisson's  capsule,  inflammation  of,  in 

cirrhosis,  309. 
Glosso-labio-laryngeal  paralysis,  358. 
Glucose,  tests  for,  284. 
Glyceramyl,  F.  148. 
Glycerin  ointment,  F.  236. 

and  rose-water,  F.  50. 
Glycerole  of  lead,  F.  180. 

of  zinc,  F.  177. 
Glycosuria,  326. 
Gmelin's  test  for  bile,  78. 
Goitre,  534. 

exophthalmic,  250. 
Gonorrhoea,  512. 
Gonorrhoeal  ophthalmia,  344. 

rheumatism,  502. 
Gout,  502. 

treatment  of,  166,  504. 
Gouty  colic,  282. 
Gravel,  324. 
Graves's  disease,  250. 
Gregorinoid  haemoptysis,  402. 
Gregory's  powder,  F.  274. 
Grindelia  robusta,  210,  212. 
Growths,  morbid,  56. 
Guaiacum,  F.  167. 
Guinea-worm,  584. 
Gums,  signs  of  disease  concerning,  67. 

lancing,  380. 
Gurgling,  109. 
Gurjun  oil,  545. 

HEMACYTOMETER,  71. 
H^matemesis,  402,  403. 
Hematuria,  404. 
HEemophilia,  400. 
Hsemoptysis,  402. 
HsemorrhagisB,  554. 
Hsemorrhoids,  297. 
Harsh  respiration,  108. 
Haschisch  in  hydrophobia,  388. 
Hay  fever,  213. 

refuges  from,  214. 


Headache,  97,  395. 

sick,  263,  396. 
Heart-clots,  signs  of,  249. 
Heart,  dilatation  of,  246. 

diseases  of,  239. 

enlargement  of,  247. 

exhaustion  of,  253. 

fatty  degeneration  of  248. 

physicaA  diagnosis  of,  110. 

starvation,  253. 
Heatstroke,  376, 
Heller's  test  for  bile,  78. 
Hemicrania,  392. 
Hemiopia,  96, 
Hemiplegia,  361. 
Hemo-ansesthesia,  390. 
Hemorrhage,  400. 

from  bowels,  404. 

from  kidneys,  404. 

from  lungs,  402. 

uterine,  405. 
Hemorrhoids,  297. 
Hepatitis,  303, 
Hepatization,  195. 
Herpes,  540. 
Hiccough,  74. 
Hip-disease,  517. 
Hippocrates,  13, 14,  23. 
Hoang-nan,  545. 
Hob-nailed  liver,  309. 
Hodgkin's  disease,  525. 
Hoft'mann,  16. 

anodyne,  ammonia,  and  soda,  F.  47. 

anodyne,  squills,  and  morphia,  F. 
36. 
Homoeopathy,  18. 
Hooping-cough,  422. 
Hope's  mixture,  F,  224. 
Hopije-Seyler,  test  for  bile,  78. 
Hosack,  18. 
Hot-air  bath,  175. 
Hot  water  in  menorrhagia,  565. 
Humid  crackling,  107. 
Humorali.sm,  18. 
Hunter.  John,  16. 
Hunyadi  Janos  water.  270,  522. 
Hyaline  casts,  183. 

degeneration,  55. 
Hybrid  between  scarlatina  and  measles, 

420. 
Hydatids  of  kidney,  332. 

of  liver,  313. 

of  lung,  207. 
Hydrocephalus,  340. 
Hydrocyanic  acid,  F.  20. 
Hydronephrosis,  329. 
Hydropathy,  175. 
Hydrophobia,  887. 
Hydro-pneumothorax,  109,  201. 
Hygienic  management  of  consumptioUj 

232. 
HyperEEmsesthesia,  55. 

treatment  of,  149. 
Hypersesthesia,  61. 
Hypermetropia,  593,  596,  597. 
Hypertrophise,  547. 
Hypertrophy,  44. 

of  the  heart,  247, 
Hypodermic  medication,  183. 
Hypophosphites,  F.  267. 
Hyposulphite  of  sodium,  168. 
Hysteria,  390. 
Hysterical  paralysis,  363. 
Hystero-epilepsy.  391. 
Hysterotomy,  466. 


GENERAL    INDEX. 


668 


TATROMEOIIANISM,  16. 
JL  Ice,  medicated,  418. 
Ice-cap,  Ml,  ;i;!H. 
Ichorhiuiairt,  i>'.>.6. 
Ielitl>yo.sis,  448. 
Icterus,  305. 
Ileus,  '>»i. 
Impetigo,  542. 
IiicoiUiueuee  of  urine,  335. 
liKluclive  medicine,  24. 
'jifantile  paralysis,  371. 

remittent,  ilM. 
Infants'  colic,  280. 
Inllanmiation,  47. 
of  bladder.  333. 
bowels.  273. 
brain,  335. 
bronchi,  208. 
ear.  Mil 

endocardium,  242. 
eye,  343. 
kidney,  316. 
larynx,  217. 
liver,  303. 
lungs,  194. 
lymphatics,  530. 
mouth,  257. 
pericardium,  239. 
peritoneum,  275. 
pharynx,  2G1. 
pleura,  201. 
spinal  marrow,  353. 
stomach.  263. 
tonsil,  260. 
trachea,  220. 
veins,  526,  528. 
remedies  for,  141. 
Influenza,  432. 
Ingluvin,  271. 
In-growing  nail,  531. 
Inhalation,  179. 

in  phthisis.  237. 
Inhibitory  action,  364. 
Injection  for  gonorrhoea,  F.  171 ,  172,  377. 
Brou.  F.  377. 
of  lung  cavities,  237. 
Inoculation,  introduction  of,  411. 

of  tubercle,  35. 
Insane,  general  paralysis  of,  367. 
Insanity,  31)8. 
Insolatio,  376. 
Insomnia,  377. 
Inspection,  98. 

of  the  body  after  death,  131. 
Insufflator.  18(i. 
Intercostal  neuralgia,  227. 

rheumatism,  226. 
Intermittent  fever.  433. 
Intestinal  hemorrhage,  404. 

obstruction.  284. 
Intussusception,  284. 
Inunction,  178. 
Iodide  of  iron,  F.  33. 

of  lead  ointment,  F.  242. 

of  mercury.  F.  169. 

of  potassium,  F.  61,  277,  278. 

of  potassium  and  glycerin,  F.  198. 

of  potassium  and  iodide  of  sulphur, 

F.  199. 
of  sulphur  ointment,  F.  188. 
Iodine,  as  counterirritant,  149. 

ointment,  F.  234. 
Iodoform,  218,  267.  351.  426;  F.  276,  342, 

:«7,  3 18,  349.  .364.  368.  375. 
Ipecacuanlia  and  alum,  F.  24. 


Iritis,  344. 

Iron,  F.  294,  295.  296,  297,  299, 300,  301,  302, 
328,  *15. 

in  antemia,  157. 

quinine  and  strychnia,  syrup,  F.  216. 
Irregularity  of  pulse,  70. 
Irritable  uterus,  566 
Irritation,  46. 

spinal,  354. 
Ischajmia,  32. 
Ischuria,  334. 
Itch,  557. 

TABORANDI,  204. 
J  Jacksonian  epilepsy,  372. 
Jail  fever,  461. 
Jalap  and  squills,  F.  151. 
Japan,  beri-beri  in,  522. 

cholera  in,  484,  487. 

flood  fever  of,  475. 
Jaundice,  305. 
Juniper,  infusion,  F.  12. 

tar  soap,  F.  190. 

KAKKE,  of  Japan,  522. 
Keloid,  553. 
Keratitis,  344. 
Kerion,  449. 
Kibbee's  fever  cot,  141. 
Kidney,  affections  of,  315. 

cancer  of,  330. 

congestion  of,  315. 

hydatids  of,  332. 

tubercle  of,  331 . 
Kinesipathy,  177. 

Knowsley  Thornton's  ice-cap,  141,  338. 
Koumiss  in  phthisis,  234,  652. 
Kyestein,  91. 

LABIO-GLOSSO-PHARYNGEAL  paral- 
ysis, 358. 
Lactic  acid  in  croup,  223. 
Lacto-phosphate  of  calcium,  F.  257. 
Laennec,  18. 
Language,  theory  concerning,  founded 

on  aphasia,  384. 
Laparotomy,  286. 
Lardaceous"  liver,  311. 
Laryngitis,  217. 
Laryngismus  stridulus,  219. 
Laryngoscope,  119. 
Lateral  spinal  sclerosis,  357. 
Lauder  Bronton.  pathology  of  angina 

pectoris,  250. 
Laurus  nobilis,  in  ague,  438. 
Lead  and  morphia  mixttire,  F.  104. 

colic,  279. 

ointment,  F.  179,  351. 

palsv,  365. 

water  for  the  eyelids,  F.  128. 
LeclanclnS  cell,  172. 
Leeches,  145. 
Lepra,  .543. 
Leprosy  of  the  Bible,  545. 

report  of  College  of  Physicians,  545 
Leucocythsemia,  524 
Leucorrhoea.  566. 
Leuksemia,  524. 
Lice,  482. 
Lichen,  537. 
Liebig,  18. 
Liebig's  broth.  650. 

food  for  infants,  6.50. 
Lime,  syrup  of,  Trou.sseau's,  F.  247. 

use  of  in  croup,  225. 


664 


GENERAL    INDEX. 


Lime-water  and  milk,  F.  64. 
Lipsemia,  31. 

Liquid  Dover's  powder,  F.  288. 
Liquorice  aud  opium  lozenges,  F.  2-10. 
Liquor  picis  alkalinus,  F.  263. 
Lithia,  in  gout,  ■117. 
Lithiasis,  324. 
Liver,  abscess  of,  303. 

acute  yellow  atrophy  of,  307. 

afl'ections  of,  301. 

aspiration  of,  304. 

cancer  of,  312. 

cirrhosis  of,  309. 

fatty,  310. 

hydatids  of,  313. 

pigmentary  degeneration  of,  308. 

syphilitic,  312. 

tubercle  of,  313. 

waxy,  311. 
Lobelia,  F.  320. 

and  ipecacuanha,  F.  18. 
Localization  of  brain  lesions,  63,  361. 
Lock-jaw,  384. 
Locomotor  ataxy,  368. 
Logwood,  F.  326. 
Lotion  for  the  ear,  F.  132. 
Louis,  18,  24. 

Lozenges  for  hoarseness,  F.  2.39. 
Lugol's  solution.  F.  186. 
Lumbricoid  worms,  580. 
Lungs,  diseases  of,  194. 
Lupulin.  F.  305. 
Lupus,  552. 
Lymph  corpuscles,  50. 

inflammatory,  51. 

MACULiE,  547. 
Magnesia  and    ammonia    mixture, 
F.  99. 
Maize,  stigma,  334,  F.  276. 
Malarial  fever,  433. 

continued  fever,  440. 
Maltine,  235. 

Manganese,  phosphate  of,  F.  244. 
Mania,  398. 

a  potu,  395. 

from  bromides,  in  epilepsy,  307. 
MarSchal's  test  for  bile,  78. 
Marriage  of  consumptives  improper,  233. 
Massage,  177. 

Maumeni^'s  test  for  sugar,  86. 
Maxims,  therapeutic,  191. 
Measles,  419. 

German,  420. 
Mediate  percussion.  101. 
Medicinal  eruptions,  536. 
Medico-legal  examinations,  137. 
Melancholia,  398. 
Melansemia,  32. 
Melasma  supra-renal  is,  533. 
Membranous  croup,  221 . 

dysmenorrhoea,  564. 
Menilre's  disease,  347. 
Meningitis.  335. 

cerebro-spinal,  457. 

spinal,  353. 
Menorrhagia,  565. 

Menstruation  and  its  deviations,  93,  562. 
Mensuration.  99. 
Meutagra,  559. 
Mercurial  palsy,  365. 

sore  mouth,  260. 
Mercury  in  inflammation,  147. 

with  chalk  and  cinnamon,  F.  108, 

with  iron,  F.  294. 


Metallic  tinkling,  109. 

Metamorphosis  of  tissue,  retardation,  160. 

Methodism,  14. 

Methomania,  397. 

Methyl-aniline  test,  55,  311. 

Metrical  prescribing,  644. 

Miasmatic  typhoid  fever,  448. 

Microbes  of  typhoid  fever,  467. 

Microphone,  103. 

Microscopic  examination  of  urine,  82, 91. 

Miliary  aneurisms,  349. 

Milk  crust,  539. 

in  disease,  162. 

-sugar  in  urine,  326. 

transfusion,  189. 
Millon's  test  for  albumen,  83. 
Mitchell,  J.  K.,  fungous  theory  of  fe- 
vers, 436. 
Moist  sounds,  105, 107. 
Moles,  547. 
Moleschott,  18. 
Molluseum,  551. 
Monomania,  398. 
Moore's  te.st  for  glucose,  86. 
Morbilli,  419. 
Morbus  Addisonii,  533. 
Morell,  19. 

Morgagni,  case  of  reflex  paralysis,  364. 
Morphia  with  valerian,  F.  144. 
Mosquitoes  carriers  of  filariee,  584. 
Mouth,  inflammation  of,  257. 
Movement-cure,  177. 
Mucous  disease,  530. 

rale,  107. 
Mucus  in  urine,  82. 
Muguet,  258. 

Mulberry  calculus,. 92.  324. 
Multiple  embolism,  243,  528. 

sclerosis,  359. 
Mumps,  422. 

Muriate  of  ammonium,  F.  16. 
Muriatic  acid  and  honey,  F.  55. 
Murmur,  vesicular,  105. 
Murmurs  of  the  heart,  112. 
Musca:  volitantes,  96. 
Muscular  debility  in  disease,  94. 
Musk  mixture,  F.  19. 
Mustard  bathing,  176. 
Myalgia,  227,  354,  501. 
Mycosis,  514. 

endocardii,  243. 
Myelitis,  353. 
Myocarditis,  242. 
Myopia,  593,  596,  598 
Myxoedema,  523. 

]VT.5:VUS,  547. 
l^    Nail,  ingrowing,  531. 
Nasal,  catarrh,  chronic,  215. 
Naturalism,  17. 
Nausea,  68. 

Nearsightedness,  593,  596.  598. 
Nephritis,  316. 

Nerve-stretching,  370.  375,  395. 
Nervous  system,  affections  of,  335, 

pathology  of,  60. 
Nettle-rash,  537. 
Neural.gia,  392. 

cutis,  555. 
Neurasthenia.  63. 
Neurataxia,  390. 
NeuropathologJ^  60. 
Neuroses,  193,  555. 
Neurotic  theory  of  gout,  503. 
Neurotomy,  395. 


GENE  It  A  L    INDEX, 


605 


Neutral  mixture,  F.  149. 
Night  terrors,  378. 
Nitrate  of  iron.  F.  3'28. 

of  potassium,  F.  4. 

in  inflammation,  147. 

pills,  F.  G2. 

silver  in  chronic  inflammations,  150. 

solution,  F.  20. 

urea,  8^1,  8ii. 
Nitre,  F.  309,  310,  311,  ,313. 
Nitric  acid,  F.  166. 
Nitrite  of  amyl,  27,  250,  374.  381,  387. 
Niti'oglycerin.  374. 
Nitro-miiriatic  acid,  F.  21,  293. 

etc.,  F.  105. 
Nosology,  192. 
Nummular  sputa.  74,  228. 
Nurses'  sore-mouth,  260. 
Nutmeg  liver.  309. 
Nux  vomica.  F.  279,  293,  295,  298,  300. 

colocynth,  and  soap,  F.  84. 

iron,  and  quinine,  F.  71. 

tincture,  F.  3-1. 

OBSTRUCTION  of  bowels,  284. 
Occipital  pressure  a  cause  of  trismus 
nascentium,  385. 
Odontalgia,  395. 
CEdema  of  the  glottis,  217. 
CEsoiihagus.  stricture  of,  262. 
Oidium  albicans.  2.")8. 
Oil,  for  biliary  calculus,  282. 

of  cajuput,  F.  79. 

turpentine  mixture,  F.  147. 
Oinomania,  3'J7. 

Ointment  of  galls  and  opium,  F.  118. 
Oleate  of  mercury,  276. 

of  zinc,  F.  3-52. 
Olive  oil  and  laudanum,  F.  133. 
Onychia,  .'i31. 
Ony.xis,  531. 
Oopliorectomv.  569. 
Ophthalmia,  343. 
Ophthalmoscope,  121,  337. 
Opisthotonos.  3,<i. 
Opium,  in  intlammation,  148. 

and  ipecacuanha,  F.  87. 

camphor,  and  hyoscyamus,  F.  145. 

suppositories,  F.  124. 

wool,  F.  314. 
Oppression.  155. 
Optic  neuritis,  123. 
Organic  degeneration,  management  in, 

171. 
Organography,  98. 
Organs,  general  pathology  of,  44. 

morbid  states  of,  25. 
Orthopncea,  73. 
Otalgia,  346. 
Otitis,  316. 
Ovarian  cells,  407. 

dropsy,  4(I6. 
Ovaries,  prolapse  of,  .573. 
Oxalate  of  cerium  for  cough.  210. 

of  lime  calculus.  92. 
Oxalates  in  urine,  80. 
Oxide  of  zinc  ointment,  F.  181. 
Oxyuris  vermicularis,  581. 
Ozoena,  215. 

P.VIN,  94. 
Painter's  colic,  279. 
I'alpation,  99. 
Palpitation,  09,  252. 
Palsy,  360. 

56* 


Panada,  649. 
Pancreatic  liquor,  271. 
PapuUe,  .537. 
Paracentesis  abdominis,  408. 

pericardii,  241. 

thoracis,  204. 
Paralysis,  360. 
Paralytic  dementia,  367. 
Paraplegia,  363. 
ParasitictE,  556. 
Parasites,  585. 
Parasitic  anemia,  519. 
Paronychia,  531. 
Parotitis  contagiosa,  422. 
Parry's  disease,  250. 
Pathology,  general,  25. 

special,  194. 
Pectoriloquy,  105. 
Pellagra,  544. 
Pelletierine,  577. 
Pelvic  htematocele,  573. 
Pemphigus,  541. 
Pepsin,  271. 

vegetable,  271. 
Percussion,  101. 
Pericarditis,  239. 
Perinephritic  abscess,  330. 
Periodic  catarrh,  213. 
Peritoneal  transfusion,  190. 
Peritonitis.  275. 
Peri-typhlitis,  274. 
Pernicious  anaemia,  519. 

fever.  445. 
Perspiration  in  disease,  93. 
Pertussis,  422. 
Pessaries,  568. 
Petechial  fever,  4.57. 
Petroleum  in  phthisis.  2.3.5. 
Pettenkofer's  test  for  bile,  78. 
Pharyngitis,  261. 
Philinus,  14. 
Phlebitis,  526,  .528. 
Phlegmasite,  192. 
Phosphate  of  iron,  F.  142. 

of  lime  calculus,  91. 

of  manganese,  F.  244. 

of  sodium  for  biliarj-  calculus.  282. 
Phosphates  and  hypophosphites,  158. 

in  urine,  90. 
Phosphoric  acid,  F.  296,  299. 
Phosphorized  oil,  F.  2.52. 
Phosphorus,  F.  270,  272,  273,  298. 

pills,  F.  246,  253. 
Photophobia,  96. 
Photopsia,  96. 
Phreuitis,  335. 
Phthisis  pulmonalis,  227. 

communication  of,  232. 

in  early  life,  238. 

pathology  of,  39,  231. 
Physical  diamosis,  98. 
Physiological  medicine,  20. 

therapeutics,  23. 
Picric  acid,  test  for  albumen,  84. 
Picrotoxiu  in  epilepsy,  308. 
Pigment  liver,  :308. 
Piles.  237. 

injection  for.  299. 
Pilocarpin,  187,  212,  311,  357. 
Pinel.  20. 

Piorry's  pleximeter,  101. 
Piscidia,  164. 

Pitch,in  auscultation  and  percussion,  103. 
Pitting,  in  small-pox,  prevention  of,  411. 
Pityriasis,  543. 


666 


GENERAL    INDEX. 


Pityriasis  versicolor,  560. 

Plague,  473. 

Plaster  jacket  for  spinal  disease,  516. 

Pleurisy,  201. 

Pleurodynia,  226. 

Pleximeters,  101. 

Plica  polonica,  560. 

Pneumatic  aspiration.  133. 

Pneumonia,  194. 

Pneumo-hydrothorax,  109,  201. 

Pneumo-pericardium.  242. 

Pneumothorax,  102,  201. 

Podagra,  502. 

Podophyllum,  etc.,  F.  82,  824,  325. 

pills,  F.  136. 

rhubarb,  etc.,  F.  95. 
Poisons,  585. 

Poisoning,   suspected,    directions    con- 
cerning, 137. 
Poison-vine  eruption,  561. 
Poliomyelitis  anterior,  371. 
Polli.  on  sulphites  and  hyposulphites, 

168. 
Polypi  of  bowel,  298. 

uterus,  571. 
Polyuria.  325. 
Pompholyx,  541. 
Pond's  sphygmograph,  127. 
Porrigo,  558. 
Position  of  body  in  disease,  93. 

in  treatment  of  disease,  141. 
Posterior  spinal  sclerosis,  369. 
Post-mortem  examination,  134. 

-paralytic  chorea,  383. 

signs  of  inflammation,  53. 
Posture  in  intestinal  obstruction,  286. 
Potassa  wash,  F.  362. 
Pott's  disease,  516. 
Practice  of  medicine,  194. 
Pregnancy,  convulsions  of,  380. 
Prepared  chalk  and  gum  Arabic,  F.  51. 
Presbyopia,  593,  597. 
Pressure  on  iliac  spines  for  colic,  280. 
Presystolic  murmurs,  113. 
Prevention  of  cholera,  488. 

of  colic,  283. 

of  yellow  fever,  454. 
Principles  of  medicine,  25. 
Prognosis,  67. 
Progressive  locomotor  ataxy,  368. 

muscular  atrophy,  366. 

pernicious  anasmia,  519. 
Prolapsus  ani,  301. 

of  ovaries,  573. 
Proliferation  of  cells,  48. 
Prolonged  expiration,  104. 
Prophylaxis  of  cholera  infantum,  293. 

of  malarial  fever,  447. 

of  yellow  fever,  454. 
Prurigo,  555. 

Pseudo-hypertrophic  nauscular  sclerosis, 
367. 

-leuksemia,  33,  525. 

-membranous  croup,  221. 
Psoriasis,  543. 

Psychical    apparatus,    symptoms    con- 
nected with,  97. 
Puerile  respiration,  104, 108. 
Puerperal  convulsions,  381. 

fever,  476. 
Pulmonary  apoplexy,  408. 

gangrene,  206. 
Pulsatile  vibration,  100. 
Pulsation  of  veins,  70. 
Pulse,  69. 


Pupil,  in  ataxy,  369. 

in  disease,  96. 
Purging,  in  inflammation,  146. 
Purpura,  554. 
Purpurin,  78. 
Purring  vibration.  100. 
Purulent  ophthalmia,  344. 
Pus,  52. 

in  urine,  82. 
Pustulae,  542. 
Pyaemia,  .526. 
Pyelitis,  317. 

Pylorus,  excision  of,  268. 
Pyonephrosis,  330. 
Pyothorax,  203. 
Pyrogallic  acid,  543. 
Pyrosis,  271. 
Pythogenic  fever,  464. 

QUEBRACHO,  212. 
Quinine,  antidotal  action  of,  165. 
and  chloride  of  iron,  F.  225. 
and  iron  pills,  F.  162. 
for  children,  F.  226. 
formulae  containing,  F.  270,  281.  282, 

300. 
ipecac,  camphor,  and  opium,  F.  117. 
in  pneumonia,  199. 
pills,  F.  159. 
solution,  F.  2. 
Quinsy,  260. 

RABIES  canina,  887. 
Rabies  mephitica,  889. 
Rachitis,  515. 

Radcliffe's  phosphorus  pills,  F.  246. 
Rale,  crepitant,  107. 
Ramollksement  of  the  brain,  342. 
Rasori,  17. 
Rationalism,  20. 
Rational  symptoms,  67. 
Reaction  of  degeneration,  95. 
Reagents  for  examination  of  urine,  91. 
Rectal  alimentation,  265,  267. 
Recto-abdominal  exploration,  116. 
Rectum,  prolapsus  of,  301. 
Recuperative  remedies,  157. 
Red  gum,  538. 
Red  sand  in  urine,  82,  88. 
Reducing  treatment,  144. 
Reese,  Prof,  directions  for  medico-legal 

examinations,  137. 
Reflex  paralysis,  364. 
Regions  of  the  chest,  104, 105. 
Relapsing  fever,  455. 
Relapses  in  typhoid  fever.  466. 
Remedies,  classification  of,  139. 

for  colic,  283. 

for  vomiting,  265. 

index  of.  655. 
Remittent  fever,  439. 
Renal  hemorrhage,  404. 
Renouard,  23. 
Resin  of  jalap,  F.  135. 
Resistance  in  percussion,  102. 
Resonance,  characters  of,  102. 
Resorcin,  153. 
Respiration,  artificial,  590. 

artificial,  for  apoplexy,  352. 

symptoms  afiS'ecting,  73. 
Respiratory  organs,  afleetions  of  195, 

percussion,  103. 
Rest.  162. 

in  tetanus.  386. 
Retention  of  urine,  334. 


G  E  N  E  R  A  L    IX  1)  E  X  , 


667 


Retinal  apoplexy,  519. 
Retraction  of  the  chest,  100. 
Retropharyngeal  akscess,  '.'62. 
Rhatany  ami  i)aregoric,  F.  110. 
Rheophore.s,  172. 
Rheumatism,  497. 
Rheumatoid  arthritis,  501. 
Rhinos(,-oi)y.  121. 
Rhonelial  vibration.  100. 
Rhonchi,  lOG. 
Rhubarb  pills,  F.  75. 

and  aloes.  F.  77. 

and  colocynth,  F.  76. 

magnesia  and  charcoal,  F.  241. 
Rhus  poisoning,  561. 
Rib,  resection  of,  in  pleuritic  effusions, 

205. 
Richardson's  spray  producer,  181. 

styptic  collodion,  F.  250. 
Rickets,  515. 

Rigidity,  early  and  late,  94. 
Ringworm.  509. 
Roseola,  5o7. 
Rotheln,  420. 
Round  worms,  .580. 
Rubbing  vibration,  100. 
Rubeola,  420. 
Rupia,  512. 

Rupture  of  spleen,  314. 
Rush,  18. 
Rutherford,  experiments  on  liver,  302. 

SAGO  jelly,  521. 
Salaam  convulsions,  379. 
Sales-Girons's  inhaler,  181. 
Salicvlic  acid,  499,  F.  281, 285, 286,  287,  288, 

333,  334. 
Salivation.  67,  260. 
Salts,  earthy,  In  urine,  90. 
Sanctorius,"l6. 
Sand  baths,  176. 
Sanitaria  for  children,  294. 
Sanitary  police  the  preventive  of  chol- 
era, 4fH. 
Santonin,  F.  206,  322. 

suppository,  F.  209. 

used  in  amaurosis,  note,  288. 
Sapramia,  29. 
Sarcina,  68,  270. 
Sassafras  liniment,  F.  139. 
Scabies,  557. 
Scald-head,  559. 
Scamranny,  F.  323. 
Scarlatina,  415. 

rheumatica.  432. 
Scarlet  fever,  415. 
Sciatica.  392. 
Scleroderma,  549. 
Sclerosis  of  brain,  355. 

pseudo-hypertrophic  muscular,  367. 

spinal  and  cerebral,  3.55. 
Sclerostoma  duodenale,  584. 
Scorbutic  dysentery,  506. 
Scorbutus.  505. 
Scrivener's  palsy^,  361. 
Scrofula,  33.  513. 

Scudaraore's  mixture,  modified,  F.  230. 
Scurvy,  505. 
Scybala,  285. 
Sea  sickness,  265. 
Seats  of  disease,  25. 
Seat-worms,  581. 
Secretions  in  fever,  26. 

symptoms  connected  with  75. 
Secretory  sounds  in  auscultation,  106. 


Sedative  lotion,  F.  196. 

Sediments  in  urine,  81. 

Semeiology,  67. 

Seminal  weakness,  574. 

Senega,  F.  314. 

Senna  and  pink  root  infusion.  F.  207. 

compound  powder  of,  F.  275. 

fluid  extract.  F.  208. 
Sensory  apparatus,  symptoms  connected 

with,  94. 
Septicaemia,  526. 
Serapion,  14. 
Serpents,  bites  of,  589. 
Shaking  palsy,  365. 
Ship  fever,  46"l. 
Sibilant  rhonchus,  106. 
Sick  headache,  263,  395. 
Siegle's  inhaler,  181. 
Silicates,  antiseptic,  169. 
Singultus,  74. 
Skin  disea.ses,  536. 

symptoms  affecting,  74. 
Skoda,     classification    of     percussion- 
sounds,  103. 

of  auscultatory  sounds,  105. 
Skoda's  pleximeter,  101. 
Small-pox,  409. 
Snake-bites,  589. 
Soda  and  nitre,  F.  122. 

mint,  F.  290. 

powders,  F.  229. 
Softening  of  the  brain,  342. 

of  stomach,  acute,  263. 
Soldiers,  heart-disease  in,  253. 
Solidism,  16. 
Sonorous  rhonchus,  106. 
Sore  throat,  261. 

Sorghum  vulgare  in  cystitis,  334. 
Sound,  uterine,  118. 
Spasm,  62. 
Specific  gravity  of  urine,  79. 

inflammation.  53. 
Speculum,  uterine,  117. 
Spedalsked,  545. 

Spermaceti  ointment  and  opium,  F.  119. 
Spermatorrhcea,  574. 
Spermatozoa.  83. 
Sphygmocardiograph,  128. 
Sphygmograph,  the,  124. 
Spice  poultice,  F.  70. 
Spiced  rhubarb  and  magnesia,  F.  101. 
Spigelia,  128,  F.  322. 
Spinal  caries,  516. 

irritation,  354. 

marrow,  inflammation  of,  353. 

meningitis,  353. 

paralysis,  357. 
Spiritus  mindereri  with  nitre,  F.  150. 
Spirometry,  100. 
Spleen,  affections  of,  314. 

entire  removal  of,  315. 
Splenization,  195. 
Sponge-tent,  118,  F.  248,  249. 
Sporadic  and  epidemic  inflammations 

contra.sted.  151. 
Spotted  fever,  457. 
Sprue.  519. 
Squamae,  543. 
Squills  and  digitalis,  F.  10. 

and  paregoric,  F.  15. 

and  tartar  emetic.  F.  14. 

nitre  and  digitalis,  F.  13. 
Stahl,  16. 
Stethoscope.  103. 
Stercoraceous  vomiting,  68,  2&1. 


668 


GENERAL    INDEX. 


Stercorin ,  93. 

Sterility,  treatment  of,  564, 

Stertorous  breathing,  74. 

Stevens's  saline  draught,  T.  245. 

Sthenic  and  asthenic  inflammatious,  150. 

system,  16. 
Stimulant  treatment,  157. 
Stimulating  embrocation,  F.  185. 

liniment,  F.  138. 
Stimulation,  hypodermic,  186. 
Stimulism,  19,  161. 
Stomach,  acute  softening  of,  263. 

cancer  of,  267. 

cramp  of,  279. 
I        dilatation  of,  264. 

Inflammation  of,  263. 

ulcer  of,  266. 
Stomatitis,  257. 
Stone,  324. 
Strabismus,  96. 
Strangury,  334. 
Strassburg,  test  for  bile,  78. 
Stricture  of  oesophagus,  262. 
Strongvlus  gigas,  584. 
Strophulus,  538. 
Strumous  diathesis,  33,  513. 
Strychnia,  F.  137. 

in  paralysis,  363. 
St.  Vitus's  dance,  382. 
Styptic  collodion,  F.  250. 
Styrax.  F.  357. 

Subnitrate  of  bismuth,  F.  63. 
Subsultus  tendinum,  94. 
Succussion,  98,  203. 
Sudden  death,  66. 

in  heart  disease,  249. 
Suffocation,  590. 
Sugar  in  urine,  84. 
Sulphate  of  cinchonia  pills,  F.  161. 

solution,  F.  160. 

of  zinc  and  rose-water,  F.  53. 
Sulphite  of  sodium,  F.  152. 

of  sodium  and  glycerin,  F.  184. 
Sulphites  and  hyposulphites,  168. 
Sulphur  ointment,  F.  238. 
Sulphuret  of   potassium   ointment,    F. 

183. 
Sulphuric  acid,  F.  326. 
Sulphuro-alkaline  ointment,  F.  197. 
Summer  catarrh.  213. 

complaint,  291. 
Sunstroke,  376. 
Supporting  treatment,  154. 
Suppositories,  vaginal  and  uterine,  569. 

formulEe  for,  F.  376,  377. 
Suppository  of  soap,  F.  83. 
Suppression  of  urine,  323. 
Suppuration,  52. 
Sycosis,  559. 
Sydenham,  16. 
Sylvius,  15. 
Symptomatology.  67. 
Syncope,  apoplectiform,  248. 
Syphilida,  560. 
Syphilis,  507. 

constitutional,  509. 

conveyed  by  vaccination,  413. 

promotive  of  aneurism,  254. 
Syphilitic  iritis,  345. 

liver,  312. 

paralysis,  365. 

rheumatism,  500. 
Syphilization,  511. 
System,  morbid  .states  of,  25. 
Systems  of  medicine,  13. 


TABES  DORSALIS,  368. 
Taenia,  577. 
Tannic  acid,  F.  348. 

and  opium,  F.  106. 

acid  solution,  F.  60. 

acid  wash,  F.  121. 
Tannin  lotion,  F.  205. 
Tapeworm,  577.  . 

Tar  ointment,  F.  235,  346,  349,  360. 
Tartar  emetic,  146,  F.  1,  96. 
Taste  in  disease,  68. 
Teeth,  signs  of  disease  concerning,  67. 
Tegument,  symptoms  affecting,  74. 
Temperature  in  disease,  128. 
Tenderness  on  pressure,  95. 
Tendon  reflex,  358,  368. 
Tentative  antidotal  treatment,  166. 
Tents,  dilating,  118,  F.  248,  249. 

for  typhiis,  463. 
Terror,  expression  of,  in  delirium  tre- 
mens. 97. 
Tetanus,  384. 
Tetrastoma,  579. 
Tetter,  538.  540. 
Thanatophobia,  63. 
Therapeutics,  general,  138. 
Thoracentesis.  204. 
Thoracic  myalgia,  227. 
Thrombosis,  528. 

cerebral,  349. 
Thrush,  258. 
Thudiclaum,  composition  of  urine,  89. 

douche,  216. 
Thyro-cardiac  disorder,  250. 
Thyroid  gland,  enlargement  of,  534. 
Ticks,  585. 

Tic  douloureux,  392. 
Tidy,  quantitative  determination  of  dia- 
betic sugar,  note,  84. 
Tinea  circinatus,  559. 

decalvans,  559. 

favosa,  558. 
Tinkling,  metallic,  109. 
Tinnitus  aurium,  96. 
Tissue   metamorphosis,  retardation   of, 

160. 
Todd,  18.  23. 

practice  of,  161. 
Toe-nail,  ingrowing,  437. 
Toepler-Holtz  machine,  174 
Tongue,  symptoms  concerning,  67. 
Tonics,  157. 
Tonic  spasm,  62. 
Tonsillitis,  261. 
Toothache,  395. 
Torula,  86. 
Toxaemia,  27. 
Tracheitis,  croup,  220. 
Tracheotomy  in  croup,  223. 
Traction,  abdominal,  286,  590. 
Transfusion  of  blood,  187. 
Tremor,  94.  359. 
Trichina,  581. 

Trichocephalus  dispar,  581. 
Triple  phosphate,  91. 
Trismus  nascentium,  385. 
Trommer's  test  for  glucose,  84. 
Trousseau,  18,  20. 
Trousseau's  .syrup  of  lime,  F.  247. 
Tubercle,  33. 

inoculation  of,  35. 

of  kidney,  331. 

of  liver.  313. 
Tubercula,  549. 
Tuberculosis,  33. 


GENERAL     1  N  IJ  E  X  . 


()(;f) 


TubtTCulous  meningitis,  338. 

j)nt'unionitt,  23G. 
Tiirck,  laryngoscojiist,  119. 
Tympiinitiu  sound,  1(J2. 
Tvi>hlilis,  271. 
TyplxiiJ  iL'ver,  404. 

jmt'Uiminia,  I'Jl). 

suite  in  reiuittont  fever,  440. 
Typlio-niularial  lever,  44S. 
Tvplius  lever,  4C1. 
Typical  ranges  of  temperature,  131. 

DLCER  of  stomach,  266. 
of  womb,  r)()8. 
Ulcerated  sore  throat.  262. 
Ulcerative  uudociivdilis,  243. 
Umbilical  iuthimmation  a  cause  of  tris- 
mus neonatorum,  385. 
Ursemia,  315. 
Urates,  81,  88. 
Urea,  excess  of,  89. 
Uric  acid,  82,  91. 
Urinary  calculi,  91. 
Urine,  symptoms  connected  with,  75. 

incontinence  of.  335. 

retention  of,  334. 
Urostcalith,  91. 
Urticaria,  537. 
Uterine  hemorrhage,  404,  505. 

tumors,  569. 

iilcers,  508. 

VACCINATION,  411. 
Valerian,  F.  305. 
Valves  of  the  heart.  111. 
Valvular  disease  of  the  heart,  244. 
Van  Helmont,  16. 
Varicella,  414. 
Variola,  409. 
Varioloid,  411. 
Va-seline,  F.  350,  364,  866. 
Veins,  infiammatiou  of,  526,  528. 

pulsation  of.  70. 
Venesection,  142. 
Venous  circulation  in  disease,  70. 
Veratria  ointment,  F.  29. 
Veratrum  viride,  F.  44. 
Verruca,  548. 
Vertigo,  98. 
Ve.sicul£e,  538. 
Vesicular  murmur,  105. 
Vesiculo-cavernous  respiration.  106. 
Vibration  of    the  walls  of    the   chest, 

changes  in,  100. 
Vibriones.  83. 

Vicarious  hemorrhage,  404. 
Vigilance,  morbid,  377. 
Virchow,  20. 
Vital  condition,  98. 


Vitalism,  17. 

Vitality,  depressed,  its  effect  upon  secre- 
tions, 91. 
Vitiligo,  M7. 

Vitreous  degeneration,  42. 
Vivi-section,  ()1. 
Vocal  resonance,  105, 107. 
Voice,  loss  of,  219. 
Volatile  liniment,  F.  233. 
Voltaic  electricity,  171. 
Vomiting  of  blood,  402,  403. 

as  a  symptom,  68. 

remedies  for,  265. 

WAKEFULNES.*^,  377. 
Walshe's  pleximeter,  101. 
Warner's  cordial  and  laudanum,  F.  48. 
Warts,  .548. 
Wasting  palsy.  366. 
Water  a  remedy  in  fever,  151. 
Waxy  liver,  311. 

Weight  of  organs  of  the  body,  136. 
Westphal's  symptom,  368. 
Whisper,  modified,  in  auscultation,  107. 
White  precipitate  ointment,  F.  187. 

spot  of  heart  in  soldiers,  242. 
Whitlow,  531. 
Whooping-cough,  345. 
Wild  cherry  and  lactucarium,  F.  35. 

bark,  F.  316.  317. 
Wine  of  ipecacuanha,  F.  5. 
Winter  cholera,  288. 

fever,  199. 
Womb,  hemorrhage  from,  405,  565. 
Women,  diseases  of,  diagnosis,  117. 

treatment,  562. 
Wood.  H.  C,  theory  of  fever,  27. 
Woodward's  student's  microscope,  91. 
Woorara  in  hydrophobia,  388. 
Worms,  576. 
Wristdrop,  365. 
Writer's  cramp.  361. 
Wiinderlich's  pleximeter,  101. 
Wyman's  apparatus  for  paracentesis,  205 

XERODERMA,  544. 
Xylol  in  small-pox,  411. 

YELI.OW  atrophy  of  liver,  acute,  307. 
Yellow  fever,  449. 
localities  of,  450. 
Woodward's  report  on,  451. 
■wash,  F.  232. 

ZINC,  F.  335,  340,  3.52,  300,  365,  369,  373. 
Zymoses,  192,  409. 
Zymosis,  29. 
Zymotic  diseases.  409. 
treatment  of,  167, 


THE    END. 


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pLASSEN'S  QUANTITATIVE  ANALYSIS.  Translated  by  Edgar  F. 
Smith,  Ph.D.  Inone  12mo.  vol.  of  324pp.,  with36  illus.  Cloth,  $2  00. 

nLELAND  (JOHN).    A  DIRECTORY  FOR  THE  DISSECTION  OF 
^     THE  HUMAN  BODY.    In  one  12mo.  vol.  of  178  pp.    Cloth,  $1  25. 

nLOUSTON  (THOMAS  S.)  CLINICAL  LECTURES  ON  MENTAL 
DISEASES.  "With  an  Abstract  of  Laws  of  U.  S.  on  Custody  of  the 
Insane,  by  C.  F.  Folsom,  M.D.  In  one  handsome  octavo  vol.  of  541 
pages,  illustrated  with  woodcuts  and  8  lithographic  plates.  Cloth, 
$4  00.     Just  ready.    Dr.  Folsom's  .4^«irac^  is  also  bound  separately. 

pLOWES  (FRANK).    AN  ELEMENTARY  TREATISE  ON  PRAC- 
^     TICAL  CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANA- 
LYSIS.  FromtheThirdEng.  Ed.  In  one  12mo.  vol.   Cloth,  $2  50. 

pOATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  vol.  of 
829  pp., with  339  engravings.  CI.,  $5  50;  leather,  $6  50.  Just  ready . 

pOHEN  (J.  SOLIS).  DISEASES  OF  THE  THROAT  AND  NASAL 
PASSAGES.  Third  edition,  thoroughly  revised.  In  one  handsome 
octavo  volume.     Preparing. 

pOLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY  AND 
PATHOLOGY.  With  Notes  and  Additions  to  adapt  it  to  American 
Practice.  By  Thos.  C.  Stellwagen,  M.A.,  M.D.,  D.D.S.  Inonehand- 
some  8vo.  vol.  of  412  pp  ,  with  331  illus.     Cloth,  $3  25. 

pONDIE  (D.FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES  OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In 
one  large  8vo.  vol.  of  719  pages.     Cloth,  S5  25  ;  leather,  $6  25. 

pOOPER  (B.B.)  LECTURES  ONTHE  PRINCIPLES  ANDPRACTICE 
^     OF  SURGERY.    In  one  large  8vo.  vol.  of  767  pages.    Cloth,  $2  00. 

pORNIL  (V.)  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNOSIS 
AND  TREATMENT.  Translated,  with  notes  and  additions,  by  J. 
Henry  C,  Simes,  M.D  ,  and  J.  AVilliam  White,  M.D.  In  one  8vo. 
volume  of  461  pages,  with  84  illustrations.     Cloth,  $3  75. 

pORNIL  (V.),  AND  RANVIER  (L.)  MANUAL  OF  PATHOLOGICAL 

^     HISTOLOGY.     Translated,   with  Notes  and  Additions,  by  E.  0. 

Shakespeare,  M.D.,  and  J.  Henry  C.  Simes,  M.D.    In  one  octavo 

volume  of  800  pages,  with  360  illustrations.    Cloth,  %b  50  ;  leather, 

$6  60;  very  handsome  half  Russia,  raised  bands,  $7. 


HENRY  C.   LEA'S  SON  &  CO.'S  PUBLICATIONS.  6 

QULLERIER  (A.)  AN  ATLAS  OF  VENEREAL  DISEASES.  Trans- 
Lated  .and  edited  byFuEKMAN  J.  Bumstead,  M.D.,  LL.D.  A  large 
quarto  volume  of  328  pages,  with  26  plntes  containing  about  150 
Ogures,  beautifully  colored,  many  of  them  life-size.     Cloth,  $17. 

nURNOW  (JOHN).  MEDICAL  APPLIED  ANATOMY.  In  prtss. 
See  Student's  Scries  of  Manuals,  p.  14. 

•HILTON  (JOHN  C.)  DOCTRINES  OF  THE  CIRCULATION  OF 
THE  BLOOD.  In  one  handsome  12mo.  volume  of  150  pages.  In 
press. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.     Seventh  edition, 

thoroughly  revised,  and  greatly  improved.  In  one  very  handsome 
8vo.  vol.  of  722  pages,  with  252  illustrations.  Cloth,  $5;  lea- 
ther, $6;  very  handsome  half  Russia,  $6  50. 

THE   TOPOGRAPHICAL  ANATOMY   OF   THE  BRAIN.     In 


D 


D 
D 


D 


one  quarto  volume  of  200  pages,  with  94  photographic  plates  and 
many  woodcuts.     In  press. 

\NA  (JAMES  D.)   THE  STRUCTURE  AND  CLASSIFICATION  OF 
ZOOPHYTES.     Withillust.onwood.  Inoneimp.4to.vol.  CI., $4. 
TJ&.VIS  (F.  a.)     LECTURES  ON  CLINICAL  MEDICINE.    Second 
edition    In  one  12mo.  volume  of  287  pages.     Cloth,  $1  75. 

E  LA  BECHE'S  GEOLOGICAL  OBSERVER.  Inone  large  Svo.  vol. 
of  700  pages,  with  300  illustrations.    Cloth,  $4. 

RAPER  (JOHN  C)  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents and  Practitioners  of  Medicine.  In  one  handsome  octavo  vol- 
ume of  600  pages,  with  250  illustrations.     Preparing . 

RUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MO- 
DERN  SURGERY.  From  the  SthLondon  edition.  Inoneoctavo 
volume  of  687  pages,  with  432  illus.     Cloth,  $4;  leather,  $5. 

■nUJ.\RDIN-BEATJMETZ.  DICTIONARY  OF  THERAPEUTICS, 
■^  MATERIA  MEDICA,  PHARMACY,  TOXICOLOGY  AND  MINE- 
RAL WATERS.  Translated  with  notes  and  additions.  Prejxiring. 
■nUNCAN  (J.  MATTHEWS).  CLINICAL  LECTURES  ON  THE  DIS- 
■^  EASES  OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital- 
In  one  octavo  volume  of  175  pages.    Cloth,  $1  50. 

■nTTNGLISGN  (ROBLEY).  MEDICAL  LEXICON;  A  Dictionary  of 
Medical  Science.  Containing  a  concise  explanation  of  the  various 
subjects  and  terms  of  Anatomy,  Physiology,  Pathology,  Hygiene, 
Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medi- 
calJurisprudence  and  Dentistry;  notices  of  Climate  and  of  Mineral 
Waters  j  Formulae  forOEBcinal,  Empirical  and  Dietetic  Preparation?; 
with  the  accentuation  and  Etymology  of  the  Terms,  and  the  French 
and  other  Synonymes.  New  edition.  In  one  very  large  royal  Svo. 
vol.  of  1139  pages,     Cloth,  $6  50  ;  leather,  $7  50  ;  half  Russia,  $8. 

pDIS  (ARTHUR  W.)  DISEASES  OF  WOMEN.  A  Manual  for  Stu- 
dents  and  Practitioners.  In  one  handsome  Svo.  vol.  of  576  pp., 
with  148  illustrations.     Cloth,  $3  ;  leather,  $4. 


6  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

pLLIS  (GEORGE  VINEE).  DEMONSTRATIONS  IN  ANATOMY. 
Being  a  Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection. 
From  the  eighth  and  revised  English  edition.  In  one  very  handsome 
octavo  volume  of  716  pages,  illustrated  by  249  engravings  on  wood. 
Cloth,  $4  25  ;  leather,  $5  25. 

■DMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRACTICE 
OP  GYNECOLOGY,  for  the  use  of  Students  and  Practitioners. 
New  edition,  enlarged  and  revised.  In  one  large  8vo.  volume  of 
about  900  pages,  with  about  150  original  illustrations.    In  press. 

■pRICHSEN  (JOHN  E.)  THE  SCIENCE  AND  ART  OE  SURGERY. 
A  new  American,  from  the  eighth  enlarged  and  revised  London 
edition.  In  two  large  octavo  volumes  of  about  2000  pages,  with 
about  900  illustrations.     In  press. 

■pSMARCH  (FRIEDRICH).  EARLY  AID  IN  INJURIES  AND 
ACCIDENTS.  In  one  small  12mo.  volume  of  109  pages,  with  24 
illustrations.     Cloth,  75  cents. 

pARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS. 
Third  American  edition,  specially  revised  by  the  Author.  Edited, 
withadditions,embracingtheU.  S.  Pharmacopoeia,  byErank  Wood- 
bury, M.D.     In  one  12mo.  volume  of  624  pages.     Cloth,  $2  25. 

pENWICK  (SAMUEL).  THE  STUDENTS'  GUIDE  TO  MEDICAL 
DIAGNOSIS.  From  the  third  revised  and  enlarged  London  edi- 
tion.   In  one  royal  12mo.  volume  of  328  pages.    Cloth,  $2  25. 

piNLAY SON  (JAMES).  CLINICAL  DIAGNOSIS.  A  Handbook  for 
Students  and  Practitioners  of  Medicine.  In  one  handsome  8vo. 
vol.  of  546  pages,  with  85  woodcuts.     Cloth,  $2  63. 

pLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  Fifth  edition,  revised  and  largely 
rewritten.  With  an  Appendix  on  the  Researches  of  Koch  and  their 
Bearing  on  the  Etiology,  Pathology,  Diagnosis  and  Treatment  of 
Pulmonary  Phthisis.  In  one  large  8vo.  vol.  of  1160  pages  Cloth, 
$5  60  ;  leather,  $6  50  ;  very  handsome  half  Russia,  $7.    Justready. 

A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION  ;  of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  arad  of  Tho- 
racic Aneurism.  Third  edition,  revised  and  enlarged.  In  one 
handsome  12mo.  volume  of  240  pages.     Cloth,  $1  63. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  HEART.  Second  edition,  enlarged. 
In  one  octavo  volume  of  660  pages.     Cloth,  $4  00. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES 
AFFECTING  THE  RESPIRATORY  ORGANS.  Second  andrevised 
edition.     In  one  octavo  volume  of  591  pages.     Cloth,  $4  50. 

CLINICAL  MEDICINE.     A  SYSTEMATIC    TREATISE  ON 

THE  DIAGNOSIS  AND  TREATMENT  OP  DISEASE.  Designed 
for  Students  and  Practitioners  of  Medicine.  In  one  handsome  octavo 
volume  of  799  pages.  Cloth,  $4  60;  leather,  $5  50  ;  very  handsome 
half  Russia,  raised  bands,  $6  00. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  7 

^LINT   (AUSTIN).    MEDICAL  ESSAYS.   In  one  12mo.  vol.,  pp.  210. 

Cloth,  $1  38. 
ON  PHTHISIS:  ITS  MORBID  ANATOMY, ETIOLOGY, ETC., 

a  series  of  Clinical  Lectures.     In  one  8vo.  volume  of  442  pages. 

Cloth,  $.3  60. 

THE    PHYSICAL    EXPLORATION    OF    THE    LUNGS,    BY 


MEANS    OP    AUSCULTATION    AND    PERCUSSION.      In    one 
small  12mo.  volume  of  83  pages.     Cloth,  $1. 

10LS0M  (C.  F.)  An  Abstract  of  Statutes  of  U.  S.  on  Custody  of  the 
Insane.  In  one  8vo.  vol.  of  108  pp.  Cloth,  $150.  Just  ready. 
Also  bound  with  Cloitsto/i.  on  Tnsa7iity. 

iQSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  New  edi- 
tion. In  one  large  12mo.  vol.  of  over  1000  pages,  with  about  275 
illustrations.     Fiepariiig. 

A  TEXT-BOOK  OF  PHYSIOLOGY.    English  Student's  edition. 


F 


In  one  ]2mo.  volume  of  804 pages,  with  72  illustrations.    Cloth,  $3. 

pOTHERGILL'S  PRACTITIONER'S  HANDBOOK  OF  TREATMENT. 
Second  edition,  revised  and  enlarged.  In  one  handsome  octavo 
vol.  of  about  650  pp.  Cloth,  $4  00;  very  handsome  half  Rus.,  $5  50. 
OWNES  (GEORGE) .  A  MANUAL  OF  ELEMBNTARYCHEMISTRY. 
A  new  American,  from  the  twelfth  English  edition.  In  one  royal 
12mo.  volume  of  1031  pages,  with  177  illustrations,  and  one  colored 
plate.     Cloth,  $2  75  ;  leather,  $3  25. 

pox  (TILBURY)  and  T.  COLCOTT.  EPITOME  OF  SKIN  DIS- 
EASES, with  Formulae.  For  Students  and  Practitioners.  Third 
Am.  edition,  revised  by  T.  C.  Fox.  In  one  small  12mo.  volume 
of  238  pages.     Cloth,  $1  25.     Jiist  ready. 

•pR&NKLAND  (E.)  AND  JAPP  (F,  K.)  INORGANIC  CHEMISTRY. 
In  one  handsome  volume,  with  illustrations.     Preparing. 

■DULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR 
PASSAGES.  Their  Pathology,  Physical  Diagnosis,  Symptoms  and 
Treatment.  From2dEng.ed     In  1  8vo.  vol.,pp.  475.   Cloth, $3  50. 

nlBNEY(V.  P.)  ORTHOPEDIC  SURGERY.  For  the  use  of  Prac- 
titioners  and  Students.     In  one  8vo.  vol.  profusely  illus.     Prepg. 

nOULD  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  press.  See 
Stiidents''  Series  of  Manuals,  p.  14. 

plBSON'S  INSTITUTES  AND  PRACTICE  OF  SURGERY.  In  two 
octavo  volumes  of  about  1000  pages.     Leather,  $6  50. 

pLUGE  (GOTTLIEB).  ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 
Translated  by  Joseph  Leidy,  M.D.,  Professor  of  Anatomy  in  the 
University  of  Pennsylvania,  &c.  In  one  imperial  quarto  volume, 
with  320  copperplate  figures,  plain  and  colored.    Cloth,  $4. 

pRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 
Edited  by  T.  Pickering  Pick,  F.R.C.S.  A  new  American,  from  the 
tenth  and  enlarged  London  edition.  To  which  is  added  Holden's 
"Landmarks,  Medical  and  Surgical,"  with  additions  by  AV.  W. 
Keen,  M.D.  In  one  imperial  octavo  volume  of  1023  pages,  with 
564  large  and  elaborate  engravings  on  wood.  Cloth,  $6  ;  leather, 
*   $7;  very  handsome  half  Russia,  raised  bands,  $7  50.     Just  ready. 


8  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

pEEEN  (T.  HENRY).   AN  INTRODUCTION  TO  PATHOLOaT  AND 
^     MORBID  ANATOMY.     Fifth  American,  from  the  sixth  London 

edition.    In  one  handsome  octavo  volume  of  482  pages,  with  150 

illustrations.     Cloth,  $2  50.     Just  ready. 

HREENE  (WILLIAM  H.)  A  MANUAL  OF  MEDICAL  CHEMISTRY, 
For  the  Use  of  Students.  Based  upon  Bowman's  Medical  Chem- 
istry.   In  one  12mo.  volume  of  310  pages,  with  74  illus.     Cloth, 

$1  75. 

QRIFFITH  (ROBERT  E.)     A   UNIVERSAL  FORMULARY,  CON- 

^    TAININ6  THE  METHODSOF  PREPARING  AND  ADMINISTER. 

ING  OFFICINAL  AND  OTHER  MEDICINES.   Thirdand  enlarged 

edition.    Edited  by  John  M.  Maisch,  Phar.D.     In  one  large  8vo. 

vol.  of  775  pages,  double  columns.     Cloth,  $4  50  ;  leather,  $5  50. 

p  ROSS  (SAMUEL  D.)  A  SYSTEM  OF  SURGERY,  PATHOLOGICAL. 

^  DIAGNOSTIC,  THERAPEUTIC  AND  OPERATIVE.  Sixth  edi- 
tion, thoroughly  revised.  In  two  imperial  octavo  volumes  contain- 
ing 2382  pages,  with  1623  illustrations.  Strongly  bound  in  leather, 
raised  bands,  $15;  very  handsome  half  Russia,  raised  bands,  $16. 

A  PRACTICAL  TREATISE  ON  THE   DISEASES,    INJU- 

ries  and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland 
and  the  Urethra.  Third  edition,  thoroughly  revised  and  much 
condensed,  by  Samuel  W.  Gross,  M.D.  In  one  octavo  volume  of 
574  pages,  with  170  illus.     Cloth,  $4  50. 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE 


AIR  PASSAGES.    Inone  8vo.  vol.  of  468  pages.    Cloth,  $2  76. 
nROSS    (SAMUEL  W.)      A   PRACTICAL   TREATISE   ON    IMPO- 
^    TENCE,    STERILITY,    AND   ALLIED   DISORDERS   OF    THE 

MALE  SEXUAL  ORGANS.     Second  edition.     In  one  handsome 

octavo  vol.  of  168  pp.,  with  16  illust.    Cloth,  $1  50. 
TJABERSHON  (S.  0.)     ON  THE  DISEASES  OF  THE  ABDOMEN, 
■^    AND  OTHER  PARTS  OF  THE  ALIMENTARY  CANAL.    Second 

American,  from  the  third  English  edition.     In  one  handsome  Svo. 

volume  of  554  pages,  with  illus.     Cloth,  $3  50. 

ITAMILTON  (ALLAN  McLANE).  NERVOUS  DISEASES,  THEIR 
DESCRIPTION  AND  TREATMENT.  Second  andrevisededition. 
In  one  octavo  volume  of  598  pages,  with  72  illustrations.   Cloth,  $4. 

TJAMILTON  (FRANK  H.)  A  PRACTICAL  TREATISE  ON  FRAC- 
TURES  AND  DISLOCATIONS.  Seventh  edition,  thoroughly  re- 
vised.  In  one  handsome  8vo.  vol.  of  over  1000  pages,  with  about 
375  illustrations.  Cloth,  $5  50;  leather,  $6  50  ;  very  handsome  half 
Russia,  $7  00. 

TTARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo. 
vol.  669  pp.  with  144  illustrations.     Cloth,  $2  75  ;  half  bound,   $3. 

A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.     In  one 


12mo.  volume  of  310  pages,  with  220  illustrations.     Cloth,  $1  7«. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  9 

ITAKTSHORNE  (HENEY).    A  CONSPECTUS  OF  THE  MEDICAL 

SCIENCES.  Comprising  Manuals  of  Anatomy,  Physiology, 
Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and 
Obstetrics.  Second  edition.  In  one  royal  12mo.  volume  of  1028 
pages,  with  477  illustralions.     Cloth,  S4  25  ;    leather,  $5  00. 

TJERMATJN  (L.)  EXPERIMENTAL  PHARMACOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Traislated  by  Robert  Mende  Smith.  M.D.  In  one  12mo.  vol. 
of  199  pages,  with  .32  illustrations.     Cloth,  SI  50. 

TIILL  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS  DIS- 
ORDERS    In  one8vo.volumeof479  pages.     Cloth,  $325. 

ITILLIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES.  2d  ed. 
In  one  royal  12mo.  volume  of  .35.3  pages,  with  two  plates.  Cloth, 
$2  25. 

TTOBLYN  (RICHARD  D.)  A  DICTIONARY  OF  THE  TERMS  USED 
IN  MEDICINE  AND  THE  COLLATERAL  SCIENCES.  In  one 
•12mo.  vol.  of  520  double-columned  pp.    Cloth,  $1  50  ;  leather,  $2. 

TTODGE  (HUGH  L.)     ON  DISEASES  PECULIAR  TO  WOMEN,  IN- 

■^  CLUDING  DISPLACEMENTS  OP  THE  UTERUS.  Second  and 
revised  edition.     In  one  8vo.  volume  of  519  pages.     Cloth,  $4  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  In  one 


large  4to.  vol.  of  542  double-columned  pages,  illustrated  with  large 
lithographic  plates  containing  159  figures  from  original  photographs, 
and  110  woodcuts.     Strongly  bound  in  cloth,  $14. 

TTOFFMANN    (FREDERICK)    AND   POWER   (FREDERICK   B.)     A 

■'-'•  MANUAL  OF  CHEMICAL  ANALYSIS,  as  Applied  to  the  E.^amina- 
tion  of  Medicinal  Chemicals  and  their  Preparations.  Third  edition, 
entirely  rewritten  and  much  enlarged.  In  one  handsome  octavo 
volume  of  621  pages,  with  179  illustrations.     Cloth,  $4  25. 

TTGLDEN  (LUTHER).  LANDMARKS,  MEDICAL  AND  SURGICAL. 
From  the  third  English  edition.  With  additions,  by  W.  W.  Keen, 
M.D.    In  one  royal  12mo.  vol.  of  148  pp.     Cloth,  $1. 

TTOLLAND  (SIR  HENRY).  MEDICAL  NOTES  AND  REFLECTIONS. 
From  .3d  English  ed.     In  one  8vo.  vol.  of  493  pp.     Cloth,  $3  50. 

TTOLMES  (TIMOTHY).  A  SYSTEM  OF  SURGERY.  With  notes  and 
adJitionsby  various  American  authors.  Edited  by  John  H.  Packard, 
M.D.  In  three  very  handsome  8vo.  vols,  containing  3137  double- 
columned  pages,  with  979  woodcuts  and  13  lithographic  plates. 
Cloth,  S18  ;  leather,  $21 ;  very  handsome  half  Russia,  raised  bands, 
$22  50.     For  sale  by  subscription  only. 

TTORNER  (WILLIAM  E.)  SPECIAL  ANATOMY  AND  HISTOLOGY. 
Eighth  edition,  revised  and  modified.  In  two  large  8 vo.  vols,  of  1007 
pages,  containing  320  woodcuts.     Cloth,  $6. 

TTUDSON  (A.)  LECTURES  ON  THE  STUDY  OF  FEVER.  In 
one  octavo  volume  of  308  pages.     Cloth,  $2  50. 

TTUTCHINSON  (JONATHAN).  SYPHILIS.  Preparing.  See  Series 
of  Clinical  Manuals,  p.  10. 


10  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

TTYDE  (JAMES  NEVINS) .  A  PRACTICAL  TREATISE  ON  DISEASES 
OF  THE  SKIN.  In  one  handsome  octavo  volume  of  570  pages, 
with  66  illust.     Cloth,  $4  25;  leather,  $5  25. 

TONES  (C.  HANDFIELD).    CLINICAL  OBSERVATIONS  ON  FUNG- 
"       TIONAL  NERVOUS  DISORDERS.    Second  American  edition.    In 
one  octavo  volume  of  340  pages.     Cloth,  $3  25. 

TULER  (HENRY)  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE 
AND  PRACTICE.  In  one  8vo.  volume,  with  many  woodcuts  and 
chromo-lithographa.     In  press. 

TTEATING  (JOHN  M.)     THE   MOTHER'S  GUIDE  IN  THE   MAN- 
•"^   AGEMBNT  AND  FEEDING  OF  INFANTS.     In  one  small  12mo. 

volume  of  118  pages.     Cloth,  $1. 
TTING  (A,  F.  A.)      A  MANUAL  OP  OBSTETRICS.    New  edition. 
In  one  12mo.  vol.  of  331  pages,  with  59  illus.  Cloth,  $2.  Just  ready. 
TTLEIN  (E  )      ELEMENTS  OF  HISTOLOGY.      In   one   pocket-size 

12mo.  volume  of  360  pages,  with  181  engravings.      Cloth,  $1  50. 

Jiist  ready.     See  Students'  Series  of  Ma7iunls,  page  14. 
T  A  ROCHE  (R.)    YELLOW  FEVER.    In  two  8vo.  vols,  of  1468  pages. 
^     Cloth,  $7. 


PNEUMONIA.    In  one  Svo.  vol.  of  490  pages.    Cloth,  $3. 


T  ATIRENCE  (J.  Z.)  AND  MOON  (ROBERT  C.)     A  HANDY-BOOK 

■^     OF  OPHTHALMIC  SURGERY.     Second  edition,  revised  hy  Mr. 

Laurence.     In  one  Svo.  vol.  pp.  227,  with  66  illus.     Cloth,  $2  75. 

T  AWSON  (GEORGE) .  INJURIES  OF  THE  EYE,  ORBIT  AND  EYE- 
LIDS. From  the  last  English  edition.  In  one  handsome  octavo 
volume  of  404  pages,  with  92   illustrations.     Cloth,  $3  50. 

T  EA  (HENRY  C.)  SUPERSTITION  AND  FORCE  ;  ESSAYS  ON  THE 

•^  WAGER  OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL 
AND  TORTURE.  Third  edition,  thoroughly  revised  and  greatly 
enlarged.    In  one  handsome  royal  12mo.  vol.  pp.  552.    Cloth,  $2  50. 

STUDIES  IN  CHURCH  HISTORY.     The  Rise  of  the  Temporal 

Power — Benefit  of  Clergy — Excommunication.  New  edition.  In 
one  handsome  12mo.  vol.  of  605  pp.    Cloth,  $2  50. 

AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 

IN  THE  CHRISTIAN  CHURCH.  Second  edition.  In  one  hand- 
some octavo  volume  of  684  pages.     Cloth,  $4  50.     Just  ready. 

TEE   (HENRY)  ON  SYPHILIS.     In  one  8vo    volume  of  246  pages. 

•^     Cloth,  $2  25. 

TEHMANN  (C.  G.)  A  MANUAL  OF  CHEMICAL  PHYSIOLOGY. 
In  one  Svo.  vol.  of  327  pages,  with  41  woodcuts.    Cloth,  $2  25. 

T  EISHMAN  (WILLIAM) .  A  SYSTEM  OF  MIDWIFERY.  Includ- 
ing  the  Diseases  of  Pregnancy  and  the  Puerperal  State.  Third 
American,  from  the  third  English  edition.  With  additions,  by 
J.  S.  Parry,  M.D.  In  one  octavo  volume  of  740  pages,  with  205 
illustrations.     Cloth,  $4  50  ;  leather,  $5  50  ;    half  Russia,  $6. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  IT 

TUCAS  (CLEMENT).  DISEASES  OP  THE  URETHRA.  Preparivg. 
See  Series  of  Clinical  Manual s,  p.  1.3. 

TTIDLOW(J.  L.)    A   MANUAL  OF  EXAMINATIONS  UPON  ANA- 

■*-'  TOMY,  PHYSIOLOGY,  SURGERY,  PRACTICE  OP  MEDICINE, 
OBSTETRICS.  MATERIA  MEDICA,  CHEMISTRY,  PHARMACY 
AND  THERAPEUTICS.  To  which  is  added  a  Medical  Formulary. 
Third  edition.  In  one  royal  12iuo.  volume  of  81G  pages,  with  .370 
woodcuts.     Cloth,  $3  25;   leather,  $3  76. 

T  YONS  (ROBERT  D.)  A  TREATISE  ON  FEVER.  In  one  octavo 
volnme  of  362  pages.     Cloth,  $2  25. 

■jyrAISCH  (JOHN  M.)  A  MANUAL  OP  ORGANIC  MATERIA  MED- 
ICA. New  edition.  In  one  handsome  12mo.  volume  of  about  500 
pnges,  with  about  200  beautiful  illustrations.     Preparing. 

TUTARSH  (HOWARD).  DISEASES  OF  THE  JOINTS.  Preparivg. 
See  Series  of  Clinical  Manuals,  p.  13. 

■jUTEIGS  (CHAS.  D.)    ON  THE  NATURE,  SIGNS  AND  TREATMENT 

■"of  CHILDBED  FEVER.    In  one  8vo.  vol.  of  346  pages.    Cloth,  $2. 

TV/riLLER  (JAMES).  PRINCIPLES  OF  SURGERY.  Fourth  American, 
from  the  third  Edinburgh  edition.  In  one  large  octavo  volume  of 
688  pages,  with  240  illustrations.     Cloth,  $3  75. 

TV/TILLER  (JAMES).  THE  PRACTICE  OF  SURGERY.  Fourth 
American,  from  the  last  Edinburgh  edition.  In  one  large  octavo 
volume  of  682  pnges,  with  364  illustrations.     Cloth,  $3  75. 

TUriTCHELL  (S.  WEIR).  LECTURES  ON  NERVOUS  DISEASES, 
ESPECIALLY  IN  WOMEN.     Second  edition.     Preparing. 

TUrOIlRIS  (HENRY).     SURGICAL  DISEASES  OF  THE  KIDNEY. 

•*•      Preparing.     See  Series  of  Clinical  Ma?mals,  p.  13. 

TWrORRIS  (MALCOLM).  SKIN  DISEASES:  Including  their  Defini- 
tions,  Symptoms,  Diagnosis,  Prognosis,  Morbid  Anatomy  and 
Treatment.  A  Manual  for  Students  and  Practitioners.  In  one 
12mo.  vol.  of  316  pages,  with  illustrations.    Cloth,  $1  75. 

MiJLLER  (J.)  PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY. 
In  one  large  8vo.  vol.  of  623  pages,  with  5.38  cuts.  Cloth,  $4  50. 
NEILL  (JOHN)  AND  SMITH  (FRANCIS  G.)  A  COMPENDIUM  OF 
THE  VARIOUS  BRANCHES  OF  MEDICAL  SCIENCE.  In  one 
handsome  12mo.  volume  of  974  pages,  with  374  woodcuts.  Cloth, 
$4;  leather,  raised  bands,  $4  75. 

NETTLESHIP'S  STUDENT'S  GUIDE  TO  DISEASES  OF  THE  EYE. 
Second  edition.  In  one  royal  12mo.  volume  of  419  pages,  with  138 
illustrations.  Cloth,  $2  00. 
WEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN.  Pre- 
paring.  See  Series  of  Clinical  Manuals,  p.  13. 
P ARRISH  (EDWARD) .  A  TREATISE  ON  PHARMACY.  With  many 
^  Formula  and  Prescriptions.  Fifth  edition,  enlarged  and  thoroughly 
revised  by  Thomas  S.  Wiegand,  Ph.G.  In  one  octavo  volume  of 
1093  pages,  with  257  illustrations.  Cloth;  $5  ;  leather,  $6.  Just 
ready. 


0 


12         HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 


pARRY  (JOHN  S.)  EXTRA-UTERINE  PREGNANCY,  ITS  CLIN- 
ICAL HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREAT- 
MENT.    In  one  octavo  volume  of  272  pages.     Cloth,  $2  50. 

pARVIN  (THEOPHILUS).  A  TREATISE  ON  MIDWIFERY.  In  one 
handsome  8vo.  vol.  of  about  550  pp. ,  with  many  illus.     In  press. 

p AVY  (F.  W.)  A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION, 
ITS  DISORDERS  AND  THEIR  TREATMENT.  From  the  second 
London  edition.    In  one  octavo  volume  of  238  pages.    Cloth,  $2. 

pEPPER  (A,  J.)  FORENSIC  MEDICINE.  Li  press.  See  SUi.de7it's 
Series  of  Manuals,  p.  14. 


SURGICAL  PATHOLOGY.    In  one  12mo.  volume  of  511  page.s 

with  81  illustrations.  Cloth,  $2.  Jusi  ready.  See  Students'' 
Series  of  Mamials,  page  14. 

piCK  (T.  PICKERING)  .  FRACTURES  AND  DISLOCATIONS.  Pre- 
pariyig.     See  Series  of  Clinical  Mannals,  p.  13. 

piRRIE  (WILLIAM),  THE  PRINCIPLES  AND  PRACTICE  OF  SUR- 
GERY. In  one  handsome  octavo  volume  of  780  pages,  with  316 
illustrations.     Cloth,  $3  75. 

pLAYFAIR  (W.  S.)  A  TREATISE  ON  THE  SCIENCE  AND  PRAC- 
TICE OF  MIDWIFERY.  Third  American  edition,  specially  revised 
by  the  Author.  Edited,  with  additions,  by  R.  P.  Harris,  M.D. 
In  one  octavo  volume  of  659  pages,  with  183  woodcuts  and  two 
plates.     Cloth,  $4;  leather,  $5;  half  Russia,  raised  bands,  $5  50. 

THE  SYSTEMATIC  TREATMENT  OF  NERVE    PROSTRA- 

TION  AND  HYSTERIA.    In  one  12mo.  vol.of  97  pages.    Cloth,  $1. 

pOLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  EAR  AND  ITS  DIS- 
EASES. Translated  at  the  Author's  request  by  James  Patterson 
Cassells,  M.D.,  F.F.P.S.  In  one  handsome  octavo  volume  of  800 
pages,  with  257  original  illustrations.    Cloth,  $5  50. 

pOWER  (HENRY).  HUMAN  PHYSIOLOGY.  In  one  ]2mo.  volume 
of  396  pages,  with  47  illustrations.  Cloth,  $1  50.  Jitst  ready.  See 
Students'  Series  of  Manuals,  page  14. 

"DALFE  (CHARLES  H.)  CLINICAL  CHEMISTRY.  In  one  12mo. 
volume  of  314  pages,  with  16  illustrations.  Cloth,  $1  50.  Just 
ready.      See  Sticdents'  Series  of  Manuals,  page  14. 

•DAMSBOTHAM   (FRANCIS   H.)     THE  PRINCIPLES  AND  PRAC- 

■^  TICE  OF  OBSTETRIC  MEDICINE  AND  SURGERY.  Inoneim- 
perial  octavo  volume  of  640  pages,  with  64  plates,  besides  numerous 
woodcuts  in  the  text.     Strongly  bound  in  leather,  $7. 

■DEMSEN(IRA).  THE  PRINCIPLES  OF  CHEMISTRY.  Second  edi- 
tion. In  one  12mo.  volume  of  240  pages.  Cloth,  $1  75.    Just  ready  ^ 

■pEYNOLDS  (J.  RUSSELL).  A  SYSTEM  OF  MEDICINE, with  Notes 
and  Additions,  by  Henry  Haetshorne,  M.D.  In  three  large  8vo. 
vols.,  containing  3056  closely  printed  double-columned  pages,  with 
317  illus.  Per  vol.,  cloth,  $5;  leather,  $6;  very  handsome  half 
Russia,  $6  50.  For  sale  by  subscription  only. 
TIICHARDSON  (BENJAMIN  W.)  PREVENTIVE  MEDICINE.  In 
■^  one  octavo  volume  of  729  pages.  Cloth,  $4;  leather,  $5;  half 
Russia,  $5  50.     Just  ready. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  13 

■ROBERTS  (JOHN  B.)     THE    PRINCIPLES    AND   PRACTICE    OF 

SURGERY.  In  one  octavo  volume  of  about  500  pages,  fully  illus- 
trated. Preparing. 
POBERTS  (WILLIAM).  A  PRACTICAL  TREATISE  ON  URINARY 
AND  RENAL  DISEASdilS.  Fourth  American,  from  the  fourth 
London  edition.  With  numerous  illustrations  and  a  colored  plate. 
In  one  very  handsome  8ro.  vol.  of  over  600  pnges.  I>i  press. 
•pOBERTSON    (J.  McGREGOR).      PHYSICAL    PHYSIOLOGY.      In 

press.     See  Students''  Series  of  Mcniuals,  p.   11. 

OARGENT  (F.  W.)  ON  BANDAGING  AND  OTHER  OPERATIONS 

*^     OF  MINOR  SURGERY.     New  edition,  with  an  additional  chapter 

on  Military  Surgery.    In  one  handsome  royal  12mo.  volume  of  383 

pages,  with  187  woodcuts.     Cloth,  $1  75. 

QfAVAGE    (GEORGE   H.;      INSANITY,    INCLUDING   HYSTERIA. 

Preparing.     See  Series  of  Cli7iical  Manuals,  p    1.3. 
nCHMITZ    AND    ZUMPT'S   CLASSICAL  SERIES,     In  royal  ISmo. 
•^     ADVANCED  LATIN  EXERCISES.    Cloth,  60  cents  ;  half  bound, 
70  cents. 
SALLUST.     Cloth,  60  cents;  half  bound,  70  cents. 
NEPOS.     Cloth,  60  cents;  half  bound,  70  cts. 
VIRGIL.     Cloth,  85  cents;  half  bound,  $1. 
CURTIUS.     Cloth, BOcents;  halfbound,90cents. 
CNCHOEDLER (FREDERICK)  AND MEDLOCK (HENRY).  AVONDERS 
OF    NATURE.     An   elementary   introduction  to    the  Sciences   of 
Physics,  Astronomy,  Chemistry,  Mineralogy,  Geology ,  Botany,  Zool- 
ogy and  Physiology.     Translated  from  the  German  by  H.  Medlock. 
In  one  Svo.  vol.,  with  679  illustrations.    Cloth,  $3. 
OCHREIBER  (JOSEPB).     A  MANUAL  OF  TREATMENT  BY  MAS- 
•^     SAGE  AND  METHODICAL   MUSCLE  EXERCISE.      Translated 
by  Walter  Mendelson,  M.D.     In  one  octavo  volume  of  about  300 
pages,  with  about  125  engravings.     Preparing. 
QJEILER  (CARL).     A  HANDBOOK  OF  DIAGNOSIS  AND  TREAT- 
*^      MENT  OF  DISEASES  OF  THE  THROAT  AND  NASAL  CAV- 
ITIES.    Second  edition.     In  one  very  handsome  12mo.  volume  of 
294  pages,  with  77  illustrations.     Cloth,  $1  75. 
SERIES  OF  CLINICAL  MANUALS.    A  series  of  authoritative  mono- 
graphs  on  important  clinical  subjects,  in   12mo.  volumes  of  about 
500  pages.     The  appended  list  of  authors  and  titles  will  give  an  idea 
of  the  general  plan  :   Hutchinson  on  Syphilis  ;  Savage  on  Insanity, 
including  Hy?  teria ;    Bryant  on  the  Breast;    Treves  on  Intestinal 
Obstruction  ;  Morris  on  Surgical  Diseases  of  the  Kidney  ;  Broadbent 
on  the  Pulse  ;  Butlin  on  the  Tongue  ;   Owen  on  Surgical  Diseases 
of  Children  ;  Lucas  on  Diseases  of  the  Urethra  ;  Marsh  on  Diseases 
of  the  Joints;  Pick  on  Fractures  and  Dislocations. 
OIMON  (W.)       MANUAL   OF  CHEMISTRY.     A  Guide  to  Lectures 
and  Laboratory  work  for  Beginners  in   Chemistry.     A  Text  book 
specially  adapted  to  Students  of  Pharmacy  and  Medicine.     In  one 
12mo.  volume  of  400  pages,  with  17  woodcuts  and  9  plates  of  actual 
deposits.     In  press. 


14  HENRY  C.   LEA'S  SON  &  CO.'S  PUBLICATIONS. 

OKEY  (PaEDERIC  C.)  OPERATIVE  SURGERY.  In  one  8vo.  vol. 
of  661  pages,  with  81  woodcuts.     Cloth,  $3  25. 

QLADE(D.D.)    DIPHTHERIA;  ITS  NATURE  AND  TREATMENT. 

Second  edition.     In  one  royal  12mo.  vol.  pp.  158.     Cloth,  $1  25. 
OMITH  (EDWARD).    CONSUMPTION;  ITS  EARLY  AND  REME- 

DIABLE  STAGES.     In  one  8vo.  vol.  of  253  pp.     Cloth,  $2  25. 

gMITH  (HENRY  H.)  AND  HORNER  (WILLIAM  E.)  ANATOMICAL 
ATLAS.  Illustrative  of  the  structure  of  the  Human  Body.  In  one 
large  imperial  8  vo.  vol.,  with  about  6  50  beautiful  figures.  Clo.,$4  50 

OMITH  (J.LEWIS).    A  TREATISE  ON  THE  DISEASES  OF   IN 
*^     FANCY  AND  CHILDHOOD.    Fifth  edition,  revised  andenlarged 
In  one  large  Svo.  volume  of  836  pages,  with  illustrations.    Cloth 
$4  50;  leather,  $5  50  ;  very  handsomehalf  Russia,  raised  bands,  $6 
OTILLE  (ALFRED).    THERAPEUTICS  AND  MATERIA  MEDIC  A 
Fourth  revised  edition.     In  two  handsome  octavo  volumes  of  1936 
pages.    Cloth, $10;  leather, $12;  very  handsome  half  Russia,  $13. 
OTILLE    (ALFRED)  AND  MAISCH  (JOHN  M.)     THE  NATIONAL 
'^     DISPENSATORY:     Containing  the  Natural  History,  Chemistry, 
Pharmacy.  Actions  and  Uses  of  Medicines.     Including  ttose  rec- 
ognized in  the  Pharmacopoeias  of  the  United  States,  Great  Britain 
and    Germany,   with  numerous  references  to  the  French  Codex. 
Third  edition,  thoroughly  revised  and  greatly  enlarged.     In  one 
magnificent  imperial  octavo  volume  of  1768  pages,  with  311  accu- 
rate engravings  on  wood.     Cloth,  $7  25  ;  leather,  raised  bands,  $8 ; 
very  handsome  half  Russia,  raised  bands  and  open  back,  $9.     Just 
ready.     Also,  furnished  with  Dennison's  Ready  Reference  Indexfor 
$1  in  addition  to  price  in  any  of  the  above  styles  of  binding. 

OTIMSON  (LEWIS  A.)  A  PRACTICAL  TREATISE  ON  FRAC- 
TURES.  In  one  handsome  octavo  volume  of  684  pages,  with  360 
beautiful  illustrations.    Cloth,  $4  75  ;  leather,  $5  75. 

A  MANUAL  OF  OPERATIVE  SURGERY.    In  one  royal  12mo. 

volume  of  477  pages,  with  332  illustrations.     Cloth,  $2  50. 

OTOKES    (W.)     LECTURES    ON    FEVER.     In  one   8vo.    volume. 

^     Cloth,  $2. 

qiTJDENTS'  SERIES  OF  MANUALS.  A  series  of  fifteen  Manuals  by 
eminent  teachers  or  examiners.  The  volumes  will  be  pocket-size 
12mos.  of  from  300-540  pages,  profusely  illustrated,  and  bound  in 
red  limp  cloth.  The  following  volumes  may  now  be  announced  : 
Klein's  Elements  of  Histology,  $1  50  ;  Pepper's  Surgical  Pathology, 
$2  00  ;  Treves'  Surgical  Applied  Anatomy,  $2  00  ;  Power's  Human 
Physiology,  $1  50  ;  Ralfe's  Clinical  Chemistry,  $1  50  ;  Clarke  and 
Lockwood's  Dissector's  Manual,  $1  50  ;  and  Bruce's  Materia  Medica 
and  Therapeutics,  just  ready.  Robertson's  Physical  Physiology, 
$1  50  ;  Bellamy's  Operative  Surgery,  Bell's  Comparative  Physio- 
logy and  Anatomy,  Gould's  Surgical  Dingnosis,  Pepper's  Forensic 
Medicine,  and  Curnow's  Medical  Applied  Anatomy,  i7i  press.  TUp 
remaining  volumes  are  in  preparation. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  15 


aXURGES    (OCTAVIUS).    AN  INTRODUCTION   TO  THE  STUDY 
•^     OF  CLINICAL   MEDICINE.     In  one  12rao.  vol.    Cloth,  $125. 

rPANNER  (THOMAS  HAWKES) .  A  MANUAL  OF  CLINICAL  MEDl- 
•*■     CINE  AND  PHYSICAL  DIAGNOSIS.    Third  American  from  the 
second  revised  English  edition.    Edited  by  Tilbury  Fox,  M.  D.    In 
one  handsome  12mo.  volume  of  362  pp.,  with  illus.     Cloth,  $1  50. 

ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    From 

the  second  English  edition.  In  one  8vo.  volume  of  49(1  pages,  with 
four  colored  plates  and  numerous  woodcuts.     Cloth,  $4  25. 

rPAYLOR  (ALFRED  S.)  MEDICAL  JURISPRUDENCE.  Eighth 
American  from  tenth  English  edition,  specially  revised  by  the 
Author.  Edited  by  John  J.  Reese,  M.D.  In  one  large  octavo 
volume  of  937  pages,  with  70  illustrations.  Cloth,  $5;  leather, 
$G  ;  very  handsome  half  Russia,  raised  bands,  $6  50. 

ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDICAL 

JURISPRUDENCE.  Third  American  from  the  third  London  edi- 
tion. In  one  octavo  volume  of  788  pages,  with  104  illustrations. 
Cloth,  $5  50;  leather,  $6  50. 


THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURIS- 
PRUDENCE. Third  ed.  In  two  handsome  8vo.  vols,  of  1416  pp., 
with  188  illustrations.     Cloth,  $10  ;  leather,  $12.     Jnslready. 

rPHOMAS  (T.  GAILLARD).    A  PRACTICAL  TREATISE  ON  THE 

•*•     DISEASES  OF    WOMEN.    Fifth  edition,  thoroughly  revised  and 

rewritten.    In  onelarge  and  handsome  octavovolume  of  810  pages, 

with  266  illustrations.    Cloth,  $5  ;  leather,  $6  ;  very  handsome  half 

Russia,  $6  50. 

rPHOMPSON  (SIR  HEKRY) .  CLINICAL  LECTURES  ON  DISEASES 
■*■     OF  THE  URINARY  ORGANS.     Second  and  revised  edition.    In 
one  octavo  volume  of  203  pages,  with  illustrations.    Cloth,  $2  25 

rPHOMFSON    (SIR   HENRY).     THE   PATHOLOGY  AND  TREAT- 
■*■     MENTOF  STRICTURE  OF  THE  URETHRA  AND  URINARY 
FISTUL.^.     From  the  third  English  edition.     In  one  octavo  vol- 
ume of  359  pages,  with  illustrations.     Cloth,  $3  50. 

rPIDY  (CHARLES  MEYMOTT).  LEGAL  MEDICINE.  Volumes  I. 
and  II.  Two  imperial  octavo  volumes  containing  1193  pages,  with 
2  colored  plates.     Per  volume,  cloth,  $6  ;  leather,  $7.    Just  ready. 

rPDDD  (ROBERT  BENTLEY) .  CLINICAL  LECTURES  ON  CERTAIN 
■*■     ACUTE  DISEASES.    In  oneSvo.  vol.  of  320  pp.,  cloth,  $2  50. 

rpREVES  (F.)  SURGICAL  APPLIED  ANATOMY.  In  one  12mo. 
volume  of  540  pages,  with  61  illustrations.  Cloth,  $2  00.  Just 
ready.     See  StiideiUs'  Series  of  M.anuals,  page  14. 

rriREVES  (FREDERICK).  INTESTINAL  OBSTRUCTION.  Fre- 
■paring.     See  Series  of  Clinical  Idanuals,  p.  10. 


3  6  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 


WALSHE  (W.  H.)     PRACTICAL  TREATISE  ON  THE  DISEASES 
OF  THE  HEART  AND  GREAT  VESSELS.   3d  American  from  the 


W 


mUKE  (DANIEL  HACK).  THE  INFLUENCE  OF  THE  MIND  UPON 
THE  BODY.  New  edition.  In  onehandsome  8vo.  vol.  of  467  pages, 
with  2  colored  places.     Cloth,  $3.     Just  ready. 

ALSHE  (W.  H.)  PRACTICAL  TREATISE  C 
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WATSON    (THOMAS).    LECTURES  ON  THE  PRINCIPLES  AND 

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WELLS  (J.  SOELBERG).  A  TREATISE  ON  THE  DISEASES  OF 
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ON   SOME  DISORDERS    OF    THE    NERVOUS   SYSTEM   IN 

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